Accepted Manuscript

Intravesical ureteric reimplantation for primary obstructed megaureter in infants under

1 year of age

Dr Emily Jude, MBBS(Hons)., Resident Medical Officer, Dr Aniruddh Deshpande,

Mch, PhD, FRACS, Staff Specialist in Paediatric Urology and Surgery, Mr Andrew
Barker, FRACS., Paediatric Urologist and Surgeon, Dr Japinder Khosa, FRACS.,
Paediatric Urologist and Surgeon, Mr Naeem Samnakay, MMedSci, FRACS., Senior
Clinical Lecturer

PII: S1477-5131(16)30312-6
DOI: 10.1016/j.jpurol.2016.09.009
Reference: JPUROL 2350

To appear in: Journal of Pediatric Urology

Received Date: 29 May 2016

Accepted Date: 12 September 2016

Please cite this article as: Jude - E, Deshpande A, Barker A, Khosa J, Samnakay N, Intravesical ureteric
reimplantation for primary obstructed megaureter in infants under 1 year of age, Journal of Pediatric
Urology (2016), doi: 10.1016/j.jpurol.2016.09.009.

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 ACCEPTED MANUSCRIPT

TITLE PAGE

INTRAVESICAL URETERIC REIMPLANTATION FOR PRIMARY OBSTRUCTED

MEGAURETER IN INFANTS UNDER ONE YEAR OF AGE

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Dr Emily Jude - MBBS(Hons). Resident Medical Officer, Sir Charles Gairdner
Hospital, Perth, Australia
Dr Aniruddh Deshpande – Mch, PhD, FRACS. Staff Specialist in Paediatric Urology

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and Surgery, John Hunter Children’s Hospital, Newcastle, Australia
Mr Andrew Barker – FRACS. Paediatric Urologist and Surgeon, Princess Margaret

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Hospital for Children, Perth, Australia
Dr Japinder Khosa – FRACS. Paediatric Urologist and Surgeon, Princess Margaret

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Hospital for Children, Perth, Australia.
Mr Naeem Samnakay – MMedSci, FRACS. Senior Clinical Lecturer, School of
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Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of
Western Australia, Perth, Australia. Paediatric Urologist and Surgeon, Princess
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Margaret Hospital for Children, Perth, Australia.
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Runninghead: Reimplantation for primary obstructed megaureter

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Key words:
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Ureteral obstruction [C12.777.725.776] / [C13.351.968.725.776]

Urologic surgical procedures [E04.950.774]
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Infant [M01.060.703]
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Child [M01.060.406]

Word count: 2579

We have read and complied with the policy of the journal on ethical consent, as

stated in the Guide to Authors. Animal ethics are not applicable. Ethics approval

by Princess Margaret Hospital for Children - GEKO Approved Activity 6781.

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Intravesical ureteric reimplantation for primary obstructed megaureter in

infants under 1 year of age

Emily Jude a,*, Aniruddh Deshpande b, Andrew Barker c, Japinder Khosa b, Naeem

Samnakay b,d

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a Sir Charles Gairdner Hospital, Perth, Australia

b John Hunter Children’s Hospital, Newcastle, Australia

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c Princess Margaret Hospital for Children, Perth, Australia

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d School of Surgery, Faculty of Medicine, Dentistry and Health Sciences,

University of Western Australia, Perth, Australia

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* Corresponding author. Sir Charles Gairdner Hospital, Hospital Avenue,

Nedlands, 6009, Australia. Tel. +61 435 164 404

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E-mail address: emily.jude@health.wa.gov.au (E. Jude).
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Summary

Purpose
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This study aimed to assess the outcome of intravesical ureteric reimplantation

for primary obstructed megaureter (POM) performed in infants under 1 year of

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age.
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Materials and methods

A retrospective cohort study was carried out of all infants undergoing

intravesical ureteric reimplantation surgery for POM at two pediatric centers in

the 12 years between 2003 and 2014. Outcomes were compared with those of

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children aged over 1 year undergoing intravesical reimplantation for POM

during this period. Follow-up was until November 2015.

Results

Thirty-seven megaureters in 34 infants were reimplanted, at median age 5.2

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months (table). Operative success was 97%, with one out of 34 patients (3%)

requiring reoperation for recurrent ureteric obstruction. Renal preservation was

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high. One patient of 34 (3%), who had bilateral congenital renal dysplasia,

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showed evidence of decline in renal function. Five patients of 34 (15%) had

postoperative urinary tract infections (UTIs). Four (13%) of those toilet trained

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had some symptoms of lower urinary tract dysfunction (LUTD). Three patients

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(9%) who had congenitally dysplastic kidneys developed hypertension.

Comparatively, 14 children with POM underwent reimplantation over 1 year of

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age. Operative success was 86%, with two children requiring reoperation for

recurrent stenosis. Both had evidence of bladder dysfunction before surgery, and
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thickened bladder walls noted during surgery. One of 14 (7%) had a decline in
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ipsilateral renal function after recurrent stenosis. Two (14%) had postoperative

UTI. Three (25%) had evidence of LUTD.

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Discussion
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There are few data about feasibility and long-term outcomes specifically of
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ureteric reimplantation for POM in infancy. This is the first study to document

long-term outcomes of intravesical ureteric reimplantation in infancy for POM.

The recently published British Association of Paediatric Urologists consensus

statement supports delaying definitive reimplantation surgery for POM that

requires intervention until after 1 year of age. There is little evidence presented

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for this recommendation. Our study confirms the safety and feasibility of

intravesical ureteric reimplantation for POM in infants under age 1, with an

operative success rate of 97%, and high renal function preservation rate. UTI

risk improved after surgery in children > 6 months old and remained stably low

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in those < 6 months of age. Postoperative rates of LUTD were low. Hypertension

occurred in only three cases with congenital renal dysplasia.

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Conclusions

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Ureteric reimplantation in infants under 1 year of age is a safe and effective

option for managing POM that requires intervention, and compares favorably

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with those undergoing reimplantation over 1 year of age.

KEYWORDS
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Ureteral obstruction; Urologic surgical procedures; Infant; Child
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Introduction
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It is suggested that primary obstructed megaureter (POM) in infants should be

managed with temporizing measures, delaying definitive reimplantation until

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after age 1 year [1]. This study aims to show that intravesical ureteric

reimplantation for POM in infants under 1 year of age is effective and safe with
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minimal morbidity, with outcomes similar to those undergoing reimplantation

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after 1 year of age.

Materials and methods

From the operating theatre databases of the only state tertiary pediatric hospital

and private pediatric urology center, we identified all patients who underwent

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intravesical ureteric reimplantation for POM in the 12 years between 2003 and

2014 inclusive. Ethics approval was given by the Princess Margaret Hospital for

Children (GEKO Approved Activity 6781).

Data were compiled from patients’ medical records using Microsoft Excel

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(Redmond, WA, USA) 2011. Follow-up was until November 2015. The severity of

hydroureteronephrosis was graded by ultrasound measurement of the

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anteroposterior diameter (APD) in millimeters and the distal ureteric diameter

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in millimeters.

The criteria for diagnosing POM included hydroureteronephrosis with

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distal ureter > 7 mm in diameter, with either obstructed curve on nuclear

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medicine studies or evidence of obstruction on intraoperative examination by

cystoscopy, retrograde studies, or magnetic resonance urography (MRU). All

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antenatally detected cases and all cases diagnosed after treatment of urinary

tract infection (UTI) were placed on prophylactic antibiotics until definitive

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surgery.
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Indications for surgery for POM included ipsilateral function < 45% at

diagnosis or dropping below 45% during surveillance, UTI, severe

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hydroureteronephrosis, or progression in hydroureteronephrosis.

A standardized intravesical transtrigonal tunneled ureteric

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reimplantation technique after resection of the stenotic segment was used for all
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cases. Resection tapering of the ureter was performed at the clinical judgment of

the operating surgeon. A small number underwent short-term temporizing

surgery (JJ stenting, percutaneous nephrostomy, or drainage of urinoma) prior

to reimplantation (see Table 2).

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The outcomes of those reimplanted under 1 year of age were assessed.

The small group reimplanted after 1 year of age during the same period also had

their outcomes assessed as a comparison. The first primary outcome measure

was the need for repeat reimplantation surgery for restenosis. “Surgical success”

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was defined as no restenosis. The second primary outcome measure was renal

function preservation. Renal function was examined by differential function on

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nuclear medicine studies, and serum creatinine in bilateral or solitary kidney

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POM. Secondary outcomes assessed included postoperative UTI, lower urinary

tract dysfunction (LUTD), and hypertension.

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Data were statistically analyzed using Microsoft Excel and SPSS Statistics

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23 software (IBM, Armonk, NY, USA) . Data from the study group (underwent

reimplantation < 12 months of age) were compared with the comparison group
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(reimplanted > 12 months of age). Categorical data were compared using the chi-

square test. Medians of continuous data were compared using non-parametric

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tests. Statistical significance was p = 0.05.

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Results
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Preoperative demographics

A total of 37 POM in 34 infants under age 1 met the criteria for surgical
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intervention and underwent intravesical ureteric reimplantation (Table 1). Ten

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(29%) had an abnormal contralateral renal tract, three of whom had bilateral

POM. In three (9%), POM was in a solitary functioning kidney.

Twenty-one (62%) cases were detected antenatally. Thirteen (38%) were

diagnosed postnatally with no prior antenatal history. All 13 presented with

febrile culture-positive UTI. The median distal ureteric diameter was 13 mm

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(range 7.3–39 mm) and the median renal pelvis APD was 17.8 mm (range 7–

46 mm). Thirty-one (91%) had a moderate (10–14.9 mm APD) or severe

( 15 mm APD) degree of hydronephrosis. Of the remaining three cases with 5–

9.9 mm APD, two had gross intrarenal dilatation and one had a perirenal

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urinoma, in keeping with severe obstruction despite the low APD.

All had preoperative micturating cystourethrogram (28 cases, 82%) or

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cystoscopy and cystogram (6 cases, 18%) to exclude posterior urethral valves

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and vesicoureteric reflux (VUR). Thirty-two (94%) had a preoperative Mag3 or

DMSA, of whom eight (25%) also had additional imaging: four retrograde

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pyelogram (RGPG) studies at cystoscopy, two anterograde pyelogram studies at

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nephrostomy, and two magnetic resonance urograms. Two (6%) cases who did

not have nuclear imaging had a single functioning kidney with severe POM
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assessed on RGPG.

Thirteen of 31 cases with two functioning kidneys (42%) had ipsilateral

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impaired differential function (< 45%) preoperatively, of whom three had

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bilateral POM and one had an abnormal contralateral kidney. The median split

function in this group was 39% (range 25–44%). One case had a raised
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creatinine preoperatively, an infant with POM in a solitary kidney.

Sixteen (47%) cases had a culture-positive preoperative febrile UTI ,

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three of whom were antenatal diagnoses. No cases had hypertension

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preoperatively.

In comparison, 15 POM ureters in 14 patients were reimplanted over 1

year of age (Table 1). Only three in this group were diagnosed antenatally.

Eleven were postnatally diagnosed, nine after a culture-positive febrile UTI and

two with abdominal pain from obstruction.

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Temporizing measures

Ten infants (29%) (6 antenatally diagnosed) had intervention pre-

reimplantation (JJ stenting, percutaneous nephrostomy, or drainage of urinoma)

at median age 3.0 months (range 0.1–6.7 months) (Table 2). Definitive

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reimplantation was performed at median 2.7 months (range 0.1–6.2 months)

after temporizing operations, at median age 6.5 months (range 2.2–8.0 months).

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In comparison, three of the 14 (21%) who underwent surgery after age 1 year

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had pre-reimplantation temporizing surgery.

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Reimplantation surgery

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Ureteric reimplantation was performed at median age 5.2 months (range 0.1–9.2

months) (Table 3). Twenty-two (16 antenatal) cases were < 6 months old and 12
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(5 antenatal) were 6–12 months old. Patients diagnosed antenatally were

reimplanted at median age 4.9 months (range 0.1–8.6 months). Patients

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diagnosed postnatally were reimplanted at a median age of 6.2 months (range

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3.1–9.2 months).

Resection tapering was performed in 18 cases (53%) and all were JJ

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stented. Decision to resection taper was made by the operating surgeon, to allow

effective ureteric reimplantation into the infant bladder with a 5:1 tunnel length
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to ureteric diameter ratio. After reimplantation surgery, 24 out of 34 (75%) had

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JJ stents for a median 4.6 weeks (range 1–10 weeks), five had exteriorized

stenting for a median 6 days (range 1–6 days), and five had no stenting.

In comparison, eight of the 14 patients reimplanted over age 1 (57%)

underwent stented resection tapering. There was no significant difference in the

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rate of resection- tapering between the cohorts having surgery under 12 months

or over 12 months (p = 0.59).

Surgical outcomes

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The mean postoperative follow-up was 6.2 years (median 5.5 years, range 1.1–

12.4 years) (Table 4). Operative success rate was 97%. One child (3%) required

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re-operation because of recurrent vesicoureteric junction (VUJ) stenosis. The

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child had POM detected antenatally and was reimplanted at 4.1 months old.

Hydroureteronephrosis resolved postoperatively. At routine follow-up, LUTD

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with elevated post-void residuals (PVRs) was noted and managed with

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urotherapy. Hydroureteronephrosis recurred on the ultrasound scan because of

restenosis at 8.7 years old, requiring re-do reimplantation. A thick-walled

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bladder was noted at surgery.

Renal function preservation was high. One case (3%) had recorded
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deterioration in renal function postoperatively. The child had bilateral POM and
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congenitally dysplastic kidneys, was reimplanted bilaterally at 4 months of age,

and developed a mild increase in serum creatinine at age 8 years to 74 μmol/L

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(normal < 65 μmol/L).

Postoperative Mag3 was performed selectively. Thirty-two patients

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(94%) had a preoperative Mag3, and 18 (53%) had at least one postoperative
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Mag3. Asymptomatic children with postoperative resolution or improvement of

hydroureteronephrosis on ultrasound did not have a routine postoperative Mag3

scans. Of the 13 cases that had impaired ipsilateral function preoperatively,

seven had postoperative Mag3, of whom six had stably impaired function and

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one had normalization of ipsilateral function. One of the solitary kidneys with

POM had elevated creatinine preoperatively which normalized postoperatively.

Infants undergoing reimplantation < 6 months of age had a lower

preoperative febrile UTI rate (27%) than infants operated on between 6 and 12

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months of age (42%). After reimplantation surgery, the UTI rate in the < 6 month

cohort remained low at 18%, but in the 6–12 month cohort dropped to 8%. Eight

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males (28%) were circumcised in this group.

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Of the 30 patients post-toilet-training age, four (13%) had some LUTD.

One had evidence of dysfunctional voiding, one had monosymptomatic nocturnal

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enuresis, and two had non-monosymptomatic nocturnal enuresis.

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Three cases (9%) developed hypertension postoperatively. All three had

congenital dysplastic kidneys: one had POM in a single dysplastic kidney, one
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had bilateral congenital renal dysplasia, and one had contralateral multicystic

dysplastic kidney and became normotensive after nephrectomy.

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In comparison, the group reimplanted over age 1 year had surgical

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success in 12 of 14 cases (86%). Two cases, both with known LUTD and elevated

PVR prior to reimplantation surgery, developed restenosis after reimplantation.

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One was diagnosed with POM at 5.3 years of age after treatment for Enterobacter

urosepsis. He underwent ureteric reimplantation and developed recurrent

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stenosis 6.3 months after, requiring re-do reimplantation. The other presented at
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8.9 years with abdominal pain and a palpable megaureter. He underwent

reimplantation, but 2 years later developed restenosis with reduced ipsilateral

function and underwent repeat reimplantation. Both had thickened bladder

walls at surgery. Seventy-nine per cent of this comparison group had a

preoperative UTI, but the rate dropped to 14% postoperatively. Six (60%) of

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males were circumcised in this group. Three (25%) in this group had LUTD.

None had hypertension.

Discussion

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Contrary to apprehension raised in the literature [1,2] our study confirms the

safety and feasibility of intravesical ureteric reimplantation for POM in infants

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under age 1 year, with an operative success rate of 97%, and high renal function

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preservation rate. UTI risk improved after surgery in children > 6 months old

and remained stably low in those < 6 months of age. Postoperative rates of LUTD

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and hypertension were low.

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A significant portion of POM does not require intervention and can be

managed conservatively with ultrasound surveillance. There is debate about best

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management of POM when intervention is indicated in infancy. As a surgical

option, ureteric reimplantation surgery in infancy is documented [3], but there

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are few data about long-term outcomes specifically of ureteric reimplantation for
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POM in infancy [3,4]. This is the first study to document outcomes of intravesical

ureteric reimplantation in infancy for POM. The recently published British

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Association of Paediatrics Urologists consensus statement supports delaying

definitive reimplantation surgery for POM that requires intervention until after 1
C

year of age [1]. There is little evidence presented for this recommendation.
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Reimplanting a very dilated ureter into a small infantile bladder is certainly a

technical challenge, but there is little evidence to show that doing this in a 1-

year-old bladder is suddenly easier or better in terms of long-term outcome than

doing so in a 3- or 6-month-old bladder. There is evidence, including from a

recent study from our center, that reimplantation surgery in children under 1

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year of age does not result in increased rates of bladder dysfunction later on in

life [5–8].

For POM < 1 year of age, the BAPU consensus prefers medium-term

temporizing measures such as stenting, balloon dilatation, or temporary

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refluxing reimplantation [1]. If stent insertion for POM is difficult cystoscopically

then open insertion via cystotomy is described [9,10]. These measures have

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significant morbidity. There is a 21–70% risk of stent complications including

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infection, stones, or stent migration [10–13]. Many also support cutaneous

ureterostomy as an option [14,15]. There is up to 22% risk of ureterostomy

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stenosis and 31% risk of febrile UTI with ureterostomy [14,16–18]. For all these

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measures, young infants often need multiple procedures under general

anesthetic before definitive surgery is finally undertaken.

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It has been our center’s practice to offer definitive ureteric reimplantation

surgery in infancy for POM cases requiring intervention [19]. Our indications for
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surgical intervention are quite similar to BAPU guidelines; however, we do not

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wait for deterioration in split renal function to < 40% before intervention.

In a small proportion (29%), we offered temporizing interventions,

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mainly to facilitate drainage of severe POM until operating time for ureteric

reimplantation was available, or for drainage of associated urinoma. For

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definitive surgery intravesical transtrigonal tunneled reimplantation was

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preferred. This technique allows mobilization of the VUJ and dilated distal ureter

into the bladder, with dissection limited to around the ureter itself, avoiding any

retrovesical dissection that can potentially disrupt bladder innervation. If

deemed necessary, resectional and stented tapering were performed. In our

study, the rate of resection tapering in the group reimplanted > 12 months of age

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was similar to the group reimplanted < 12 months of age (p = 0.59), showing that

similar decisions about safely reimplanting dilated ureters into the older

pediatric bladder need to be made, and simply delaying surgery to > 12 months

of age will not necessarily reduce the need for resection-tapering of a very

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dilated ureter.

One child reimplanted in infancy developed restenosis. In the comparison

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group reimplanted over age 1, two developed restenosis. All three had evidence

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of bladder dysfunction and thickened bladder wall (in 2 of 3 this was noted prior

to reimplantation) that could explain the tendency for the reimplanted VUJ to

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scar excessively. Previous small series of intervention for POM describe

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restenosis rates of 2.1–17.6% [7,12,19–21]

Reduced ipsilateral renal function to < 45% was seen in 13 patients

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(42%) preoperatively, but this improved in one case postoperatively. It

remained stable in all others having a postoperative Mag3. A raised preoperative

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creatinine in a solitary kidney POM normalized postoperatively. Our data show

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early reimplantation surgery helps to maintain, and in some cases improve,

ipsilateral and overall renal function. The one case with deterioration in renal
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function had POM in bilateral dysplastic kidneys, and developed a mildly

elevated creatinine at age 8. In the comparison group reimplanted over age 1,

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one child developed ipsilateral renal function deterioration after restenosing.

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Previous small series have reported a decline in renal function after ureteric

reimplantation up to 10% [22–25].

UTI risk in POM is known to be elevated, in part because of the slowly

draining dilated upper tract, and in part to the elements of bladder dysfunction

likely associated with the condition [26–28]. Cases detected antenatally that had

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reimplantation < 6 months of age were less likely to have preoperative culture-

positive febrile UTIs than older children, and their postoperative UTI rate

remained low. The postoperative UTI rate dropped significantly in those having

surgery after 6 months of age, and also in the comparison group reimplanted

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over age 1 year.

The overall rate of LUTD was low: four out of 30 (13%) cases post-toilet-

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training age, not dissimilar to LUTD rates in the general pediatric population

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[29,30]. In the comparison group reimplanted after age 1, at least two children

had evidence of bladder dysfunction prior to reimplantation surgery. Children

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with POM may have an inherently higher risk of bladder dysfunction because of

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global urinary tract dysplasia and maldevelopment. Bladder dysfunction may

become evident later in childhood. Hypertension only occurred in those with

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congenital renal dysplasia.

The strengths of our study include a long follow-up time and low attrition
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rate. We captured all surgical cases within our state as surgery occurred in these
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two centers only, which minimizes selection bias at study entry. Imaging was

performed by the same group of diagnostic-imaging specialists, which ensures

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accurate and consistent reporting. Intravesical ureteric reimplantation surgery

was of a consistent technique. Limitations include that it is a retrospective

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review thus indications for intervention or tapering, though within broad

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practice guidelines, were at surgeon’s discretion and subject to variations

between surgeons. Mag3 was only performed postoperatively if clinically

required, though routine post-op Mag3 would have been useful for study data.

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Our center recommends follow-up with an annual renal ultrasound

throughout childhood, monitoring bladder function, treating any bladder

dysfunction and surveilling for possible long-term complications.

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Conclusion

For POM requiring intervention, surgery with resection of the stenosis, resection

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tapering if required, and intravesical ureteric reimplantation is safe and effective

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in infants under 1 year of age. Our study shows a 97% surgical success rate, high

renal function preservation rate and low rates of LUTD with this technique.

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Outcomes presented are similar to, if not better than, the outcomes of those

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undergoing reimplantation for POM over 1 year of age.
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Conflicts of interest

None.
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Funding
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None.
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References

[1] Farrugia MK, Hitchcock R, Radford A, et al. British Association of

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Paediatric Urologists consensus statement on the management of the primary

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obstructive megaureter. J Pediatr Urol 10:26–33.

[2] Antoniou D, Baltogiannis N, Soutis M, et al. Primary non-refluxing

megaureter: need for conservative treatment. Pediatr Med Chirurg 29:258–61.

[3] Lui C, Chin T, Wei C. Surgical treatment of vesicoureteral reflux in infants

under 3 months of age. J Pediatr Surg 1998;33:1716–9.

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 ACCEPTED MANUSCRIPT

[4] Peters CA, Mandell J, Lebowitz RL, et al. Congenital obstructed

megaureters in early infancy: Diagnosis and treatment. J Urol 1989;142(Pt

2):641–5.

[5] Ooi SM, Kane N, Khosa J, et al. Lower urinary tract dysfunction in children

PT
after intravesical ureteric reimplantation surgery under one year of age. J Pediatr

Urol 2014;10:1139–44.

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[6] De Jong TP. Treatment of the neonatal and infant megaureter in reflux,

SC
obstruction and complex congenital abnormalities. Acta Urol Belg 1997;65:45–7.

[7] Upadhyay J, Shekarriz B, Fleming P, et al. Ureteral reimplantation in

U
infancy: Evaluation of long-term voiding function. J Urol 1999;162:1209–12.

[8] AN
De Kort LM, Kling AJ, Uiterwaal CS, et al. Ureteral reimplantation in

infants and children: Effect on bladder function. J Urol 2002;167:285–7.

M
[9] Shenoy MU, Rance CH. Is there a place for the insertion of a JJ stent as a

temporizing procedure for symptomatic partial congenital vesico-ureteric

D

junction obstruction in infancy? BJU Int 1999;84:524–5.

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[10] Farrugia MK, Steinbrecher HA, Malone PS. The utilization of stents in the

management of primary obstructive megaureters requiring intervention before

EP

1 year of age. J Pediatr Urol 7:198–202.

[11] Castagnetti M, Cimador M, Sergio M, et al. Double-J stent insertion across

C

vesicoureteral junction—is it a valuable initial approach in neonates and infants

AC

with severe primary nonrefluxing megaureter? Urology 68:870–5; discussion 5–

6.

[12] Barbancho DC, Fraile AG, Sanchez RT, et al. [Is effective the initial

management of primary nonrefluxing megaureter with double-J stent?]. Cirug

Pediatr 21:32–6.

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[13] Carroll D, Chandran H, Joshi A, et al. Endoscopic placement of double-J

ureteric stents in children as a treatment for primary obstructive megaureter.

Urol Ann 2010;2:114–8.

[14] Kitchens DM, DeFoor W, Minevich E, et al. End cutaneous ureterostomy

PT
for the management of severe hydronephrosis. J Urol 177:1501–4.

[15] Trobs RB, Heinecke K, Elouahidi T, et al. Renal function and urine

RI
drainage after conservative or operative treatment of primary (obstructive)

SC
megaureter in infants and children. Int Urol Nephrol 38:141–7.

[16] Sarduy GS, Crooks KK, Smith JP, et al. Results in children managed by

U
cutaneous ureterostomy. Urology 1982;19:486–8.

[17] AN
MacGregor PS, Kay R, Straffon RA. Cutaneous ureterostomy in children --

long-term followup. J Urol 1985;134:518–20.

M
[18] Gearhart JP. Primary obstructive ureter in neonates. Treatment by

temporary uretero-cutaneostomy. Br J Urol 1994;74:133–4.

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[19] Sripathi V, King PA, Thompson MR, et al. Primary obstructive megaureter.
TE

J Pediatr Surg 1991;26:826–9.

[20] Garcia-Aparicio L, Blazquez-Gomez E, Martin O, et al. Use of high-pressure

EP

balloon dilatation of the ureterovesical junction instead of ureteral

reimplantation to treat primary obstructive megaureter: Is it justified? J Pediatr

C

Urol 9(Pt B):1229–33.

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[21] Suer E, Ozcan C, Mermerkaya M, et al. Can factors affecting complication

rates for ureteric re-implantation be predicted? Use of the modified Clavien

classification system in a paediatric population. BJU Int 114:595–600.

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[22] Areses Trapote R, Urbieta Garagorri MA, Ubetagoyena Arrieta M, et al.

[Prenatal detection of primary non-refluxing megaureter. Review of our

casuistics]. Anal Pediatr 67:123–32.

[23] Liu HY, Dhillon HK, Yeung CK, et al. Clinical outcomes and management of

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prenatally diagnosed primary megaureters. J Urol 1994;152:614–7.

[24] Cheskis AL, Leonova LV, Severgina ES, et al. [Renal development long after

RI
correction of primary non-refluxing forms of megaureter in children]. Urologiia

SC
2006;5:74–80.

[25] Nagy V, Baca M, Boor A. Primary obstructed megaureter (POM) in

U
children. Bratisl Lek Listy 114:650–6.

[26] AN
Lee JH, Choi HS, Kim KJ, et al. Nonrefluxing neonatal hydronephrosis and

the risk of urinary tract infection. J Urol 2008;179:1524.

M
[27] Gimpel C, Masioniene L, Djakovic N, et al. Complications and long-term

outcome of primary obstructive megaureter in childhood. Pediatr Nephrol

D

25:1679–86.
TE

[28] Song SH, Lee SB, Park YS, et al. Is antibiotic prophylaxis necessary in

infants with obstructive hydronephrosis? J Urol 2007;177:1098–101.

EP

[29] Hellström AL, Hanson E, Hansson S, et al. Micturition habits and

incontinence in 7-year-old Swedish school entrants. Eur J Pediatr 1990;149:434–

C

7.
AC

[30] Mota DM, Victora CG, Hallal PC. [Investigation of voiding dysfunction in a

population-based sample of children aged 3 to 9 years]. J Pediatr (Rio J)

2005;81:225–32.

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Table 1 Demographics and preoperative characteristics.

Comparison
Study group, n = 34 group, n= p (study
14 group vs.
comparison
Age at ureteric reimplantation surgery (months)
group)
<6 6–12 Total < 12 > 12

PT
Total 22 (46) 12 (25) 34 (71) 14 (29)

Male 20 (91) 9 (75) 29 (85) 10 (71) 0.045 *

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Female 2 (9) 3 (25) 5 (15) 4 (29)

Antenatal dx 16 (73) 5 (42) 21 (62) 3 (21) 0.011 *

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Postnatal dx 6 (27) 7 (58) 13 (38) 11 (79)

Left POM 18 (82) 9 (75) 27 (79) 11 (79)

Right POM 3 (14) 1(8) 4 (12) 2 (14)

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Bilateral POM 1 (5) 2 (17) 3 (9) 1 (7) 0.85

Single kidney
AN
3 (14) 0 3 (9) 0

Other abnormal contralateral

3 (14) 1 (8) 4 (12) 2 (14)
kidney a
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Distal ureter 7–9.9 mm b 3 (15) 2 (18) 5 (15) 1 (8)
D

Distal ureter 10–19.9 mm b 14 (70) 8 (73) 22 (65) 7 (54)

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Distal ureter 20 mm+ b 3 (15) 1 (9) 4 (12) 5 (38) 0.053

Distal ureter diameter in mm b, 13.9 (7.6–

13 (7.3–20) 13 (7.3–39) 16.5 (9–28) 0.29
median (range) 39)
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Mild hydronephrosis c 0 3 (25) 3(9) 1 (7)

Moderate hydronephrosis c 5 (23) 4 (33) 9 (26) 4 (29)

C
AC

Severe hydronephrosis c 17 (77) 5 (42) 22 (65) 9 (64) 0.97

18.6 (10–
APD in mm, median (range) 13.7 (7–28) 17.8 (7–46) 20.9 (9–34) 0.51
46)
Males circumcised
preimplantation or at 6 (30) 2 (22) 8 (28) 6 (60)
reimplantation

Pre-op UTI 7 (32) 9 (75) 16 (47) 11 (79) 0.047 *

Ipsilateral function < 45% d,e 7 (37) e 6 (50) 13 (42)e 8 (62)f

0.22
 ACCEPTED MANUSCRIPT

% Ipsilateral function of reduced 39 (25–44) 40.5 (26–43) 39 (25–44) 34 (21–39)

function cohort, median (range)

Renal impairment (raised

1 (5) 0 1 (3) 0
creatinine)
Temporizing operation prior to
5 (23) 5 (42) 10 (29) 3 (21) 0.57
reimplantation

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Note. Values are n (%) unless otherwise stated. APD = anteroposterior diameter; POM = primary
obstructed megaureter; UTI = urinary tract infection.
a Excluding single kidneys and bilateral POM.
b Of those with recorded measurement.

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c Mild hydronephrosis, APD 5–9.9 mm; moderate hydronephrosis, APD 10–14.9 mm; severe

hydronephrosis, APD ≥ 15 mm.

d Of cases with a functional contralateral kidney (3 single kidneys excluded).
e Of cases with Mag3 done (1 case > 12 months excluded).

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Table 2 Temporizing measures prior to definitive reimplantation.
Comparison

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Study group, n = 34 group, n =
14

AN
Age at ureteric reimplantation surgery (months)

<6 6–12 Total < 12 > 12

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Retrograde JJ stent for tight stenosis
4 2 6 3
at assessment cystoscopy, n
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Antegrade JJ stent for tight stenosis

1 1 2 0
at assessment cystoscopy, n
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Drainage of urinoma, n 0 1 1 0

Percutaneous nephrostomy for

0 1 1 0
severe urosepsis, n
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Total undergoing temporizing

5 (23) 5 (42) 10 (29) 3 (21)
measure, n (%)

Time from temporizing measure to

definitive reimplantation in months, 2.0 (0.1–4.8) 2.9 (0.5–6.2) 2.7 (0.1–6.2) 1.4 (0.1–1.8)
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median (range)
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Table 3 Surgical approach: tapering and stenting.

Comparison
Study group, n = 34
group, n = 14 p (study group
vs.
comparison
Age at ureteric reimplantation surgery (months)
group)

<6 6–12 Total < 12 > 12

Total 22 12 34 14
 ACCEPTED MANUSCRIPT

Tapered 12 (55) 6 (50) 18 (53) 8 (57) 0.59

Not tapered 10 (45) 6 (50) 16 (47) 6 (43)

JJ stent 15 (68) 9 (75) 24 (71) 12 (86) 0.97

Exteriorized stent 5 (23) 0 5 (15) 0

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No stent 2 (9) 3 (25) 5 (15) 2 (14) 0.96

Age at
reimplantation in
3.75 (0.1–5.9) 7.9 (6.2–9.2) 5.2 (0.1–9.2) 48.1 (12.8–131.1) < 0.001 *
months, median

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(range)
Note. Values are n (%) unless otherwise stated.

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Table 4 Postoperative outcomes.
Comparison
Study group, n = 34 group, n =
p (study

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14
group vs.
comparison
Age at ureteric reimplantation surgery (months)

<6
AN
6–12 Total <12 >12
group)

Total 22 12 34 14
M
Follow up in years, 5.5 (1.1– 5.7 (2.9– 5.5 (1.1– 4.0 (1.3–
0.34
median (range) 10.7) 12.4) 12.4) 10.7)
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Redo surgery for

1 (5) 0 1 (3) 2 (14) 0.05 *
restenosis
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Impaired renal
function (elevated 1 (5) 0 1 (3) 0
creatinine)
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Declined ipsilateral
0 0 0 1 (17)
function a

Improved renal
1 (100) 0 1 (100) 0
function b
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Improved ipsilateral
0 1 (17) 1 (8) 2 (25)
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function c

Stable impaired
7 (100) 5 (83) 12 (92) 6 (75)
ipsilateral function c

0.05 * (favors
UTI d 4 (18) 1 (8) 5 (15) 2 (14)
infants)

LUTD 2 (11) 2 (17) 4 (12) 3 (25) 0.37

Hypertension 3 (14) 0 3 (9) 0 0.25

 ACCEPTED MANUSCRIPT

Note. Values are n (%) unless otherwise stated. LUTD = lower urinary tract dysfunction; UTI =
urinary tract infection.
a Of cases with normal ipsilateral function preoperatively.
b Of cases with raised serum creatinine preoperatively.
c Of cases with reduced ipsilateral function preoperatively.
d Excludes JJ stent-associated UTI.
e Of cases over toilet-training age at end of follow–up.

PT
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AN
M
D
TE
C EP
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Table Summary of preoperative characteristics and postoperative results.

Comparison
Study group p (study vs.
group
(reimplanted comparison
(reimplanted
<12 months) group)
>12 months)

Preoperative

Total 34 (71%) 14 (29%)

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UTI 16 (47%) 11 (79%) 0.047*

Ipsilateral function < 45% a,b 13 (42%)a 8 (62%)b 0.22

Renal impairment (raised creatinine) 1 (3%) 0 –

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Temporizing operation 10 (29%) 3 (21%) 0.57

Age at reimplantation in months,

5.2 (0.1–9.2) 48.1 (12.8-131.1) < 0.001*

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median (range)

Time from diagnosis to reimplantation

3.4 (0.1–8.6) 3.8 (0.1–106) 0.75
in months , median (range)

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Postoperative

Follow-up (years)–median (range) 5.5 (1.1–12.4) 4.0 (1.3–10.7) 0.34

Redo surgery for restenosis

Decline in renal function c

AN
1 (3%)

1 (3%)
2 (14%)

1 (7%)
0.05 *
M
Improved renal function d 2 (6%) 2 (14%) 0.52

Stable impaired renal function d 13 (38%) 6 (43%)

0.05 * favors
D

UTI e 5 (15%) 2 (14%)

infants

LUTD 4 (12%) 3 (21%) 0.37

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Hypertension 3 (9%) 0 0.25

Note. Values are n (%) unless otherwise stated. LUTD = lower urinary tract dysfunction; UTI = urinary tract
infection.
EP

a Of cases with a functional contralateral kidney (3 single kidneys excluded).

b Of cases with Mag3 done (1 case > 12 months excluded).
c Includes newly raised creatinine, and decline in ipsilateral function in cases with normal ipsilateral function

preoperatively.
d Of cases with raised serum creatinine preoperatively and/or reduced ipsilateral function preoperatively.
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e excludes JJ stent-associated UTI.

f Of cases over toilet-training age at end of follow-up.
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