Journal of Pediatric Urology (2019) 15, 256.e1e256.
e5
University of Nebraska Medical
Center/Children’s Hospital and
Medical Center, 8200 Dodge
Street, Omaha, NE 68114, USA
* Corresponding author.
cvillanueva.uro@gmail.com
(C.A. Villanueva)
Keywords
Primary obstructed megaur-
eter; Megaureter; Ureteros-
tomy; Infant ureteral
reimplantation
Received 27 September 2018
Revised 2 January 2019
Accepted 14 January 2019
Available online 23 January
2019
https://doi.org/10.1016/j.jpurol.2019.01.004
1477-5131/ª 2019 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
‘Mini’ extravesical reimplant with ‘mini’
tapering for infants younger than
6 months
C.A. Villanueva *
Summary
Introduction
Some infants with obstructed megaureters or
ectopic ureters requiring surgery undergo a cuta-
neous ureterostomy followed by definitive repair
after 12 months of age. Since 2013, a ‘mini’ extra-
vesical reimplant with or without ‘mini’ tapering
(MER) was performed instead of cutaneous ureter-
ostomy in such infants.
Objective
To describe the technique and outcomes for MER.
Study Design
This is a retrospective review of infants younger
than 6 months who underwent MER. MER consists of
a 2- to 3-cm extravesical tunnel, regardless of the
ureter diameter. ‘Mini’ tapering consisted of an
adventitial sparing technique involving only the
distal 2e3 cm of the ureter. Details of the technique
are included in the video. The main outcomes were
postoperative symptomatic urinary tract infections
(UTI’s) and reoperations. Voiding function was
assessed at the last contact with the family.
Results
Nine consecutive infants underwent MER from July
2013 to March 2018. Four patients had ectopic ure-
ters and five had primary obstructed megaureters.
The median ureteral diameter was 1.5 cm.
Indications for surgery were as per the British Asso-
ciation of Pediatric Urologists guidelines on mega-
ureters. All patients had 3-month postoperative
renal ultrasound, and seven of the nine patients had
postoperative voiding cystourethrogram (VCUG).
One patient with a normal postoperative VCUG and
MAG 3, as well as resolved hydroureteronephrosis
had a few postoperative febrile UTIs but no more for
>1 year at the last follow-up. At a median time from
surgery of 44 months, there have been no reopera-
tions (except cystoscopy with stent removal). With
regard to voiding function, six patients were suc-
cessfully potty trained, one has bowel and bladder
incontinence at the age of 4 years e with stable
renal ulstraound e, and two are younger than 2
years.
Discussion
MER has been the only surgery needed for the cohort
of nine infants younger than 6 months with distal
ureteral obstruction at a median time from surgery
of 44 months. Voiding function does not appear to be
affected by the operation.
Conclusions
For babies younger than 6 months of age in need of
surgery for obstructed distal ureter, MER appears to
be a feasible and effective option, associated with
reduced morbidity and reoperation rate compared
to the alternatives.
‘Mini’ extravesical reimplant
Introduction
Some infants presenting before the age of 6e12 months
with obstructed megaureters or ectopic ureters with asso-
ciated ipsilateral renal function loss, severe hydro-
ureteronephrosis, or febrile urinary tract infection (UTI)
undergo an end cutaneous ureterostomy. Once these pa-
tients are older than 1 year, a ureteral reimplantation with
or without ureteral tapering is usually performed.
In addition to skin problems associated with constant
moisture at the ureterostomy site, all patients who undergo
diverting ureterostomy require reoperation to undivert,
40% have postoperative (PO) vesicoureteral reflux (VUR)
after the definitive repair, 40% experience a febrile UTI
while awaiting undiversion, and 31% require additional
reoperations after undiversion [1].
An alternative to a cutaneous ureterostomy for these
infants is immediate reimplantation with or without
tapering at the time of presentation. The outcomes of
primary intravesical ureteral reimplantation for obstructed
megaureters have been described by several authors. Pe-
ters et al. [2] reported on 42 megaureter repairs in infants
with mean age of 1.8 months, with 86% patients having
successful outcomes and 14% requiring a reoperation.
Greenfield et al. [3] published 97% success rates for tapered
reimplants and 100% for non-tapered reimplants for infants
8 weeks to 6 months of age. Similar outcomes in infants
younger than 3 months were published in the study by Liu
et al. [4].
More recently, Jude et al. [5] reported on 37 reimplants
for megaureters in 34 infants at a median age of 5.2
months: operative success was 97%, with 1/34 patients
(3%) requiring reoperation for recurrent ureteric obstruc-
tion. Five of 34 (20%) had PO UTIs and 13% who were toilet
trained had lower urinary tract dysfunction. The authors
compared the infant cohort with another cohort of pa-
tients older than 1 year, in whom operative success was
only 86% and PO UTI incidence was similar to the younger
group.
Concerns about PO voiding dysfunction secondary to
early ureteral reimplantation appear to be unfounded. De
Kort et al. [6] compared preoperative and PO urodynamics
in two groups of 25 children who had reimplantation before
and after 12 months of age. There was no difference in
urodynamic parameters between the groups. Ooi et al. [7]
found no evidence of lower urinary tract dysfunction in
children younger than 1 year undergoing intravesical Cohen
reimplants.
A refluxing extravesical reimplant as an alternative to
cutaneous ureterostomy has been promoted by the group in
Indiana [8]. Although devoid of the skin complications
caused by having a cutaneous ureterostomy, the refluxing
reimplant suffers from similar reoperation rates and
recurrent UTIs as the cutaneous ureterostomy.
Extravesical non-refluxing ureteral reimplantation can
be performed in less operative time with less PO discomfort
and shorter hospital stay compared with intravesical reim-
plants, with both techniques being equally effective [9].
Since 2013, infants with unilateral distal ureteral
obstruction were managed with an MER. Outcomes for
these infants are presented here.
256.e2
Materials and methods
This is a retrospective review of infants younger than 6
months who underwent MER.
MER consists of a 2- to 3-cm extravesical tunnel,
regardless of the ureter diameter. ‘Mini’ tapering consisted
of an adventitial sparing technique involving only the distal
2e3 cm of the ureter. ‘Mini’ tapering was added after VUR
was observed in two of the first four patients. Details of the
technique are included in the video.
Patients with Society of Fetal Urology grade 3e4
hydroureteronephrosis (HUN), differential renal function
less than 40%, urosepsis, or worsening HUN on serial ultra-
sound (US) were included. Patients also had to have uni-
lateral obstructive disease, ipsilateral single system
(incomplete duplications were included), and diuretic half-
time (T1/2) > 30 min.
The exclusion criteria included neurogenic bladder,
posterior urethral valves, and contralateral VUR grade 4e5.
The procedure starts with cystoscopy to differentiate the
ectopic ureter versus obstructed megaureter. A Pfannenstiel
skin incision with a midline fascial incision is performed and
the ureter is dissected and divided at the bladder if mega-
ureter or as distal as possible/safe for ectopic ureter. The
borders of the detrusorrhaphy are marked posterolaterally
with four 4-0 silk stay sutures followed by a 2- to 3-cm ‘mini’
detrusorrhaphy down to the mucosa. ‘Mini’ ureteral tapering
is performed using the technique described by Ossandon
[10]. The ureter is anastomosed with 5-0 polyglactin to the
distal detrusorraphy making only a small mucosal opening
with a distal advancement suture with 4-0 polyglactin to
secure the ureteral orifice distally in the bladder. Detrusor is
closed with interrupted 3-0 polyglactin stitches.
For non-tapered reimplants, the stent is sutured to the
Foley catheter and removed in 5e7 days in the clinic. For
tapered reimplants, the stent is removed after 1 month
under general anesthesia.
No drains are placed, and Foley catheter remains in
place for 5e7 days in all cases draining into a diaper. Pa-
tients are kept on prophylaxis for 3 months after surgery.
After surgery, patients were evaluated with renal ul-
trasound (RUS) at 3 months and 1 year. VCUG was per-
formed at 3 months and then on an as-needed basis for UTIs
or to follow up on VUR. Persistent VUR without UTI was not
considered failure; therefore, the last two patients did not
get a PO VCUG. MAG 3 was reserved for the lack of
improvement on the RUS.
Outcomes analyzed included reoperations, PO UTIs,
resolution of HUN, operative time, and voiding function.
Results
Nine consecutive infants underwent MER.
Characteristics of the patients are shown in Table 1. Two
patients presented initially with urosepsis, both females
and both not on prophylaxis at the time of presentation.
The two patients were treated with antibiotics and
responded quickly. Surgery was then performed a few
weeks later once their infection was cleared. The other
patients presented because of prenatal diagnosis of HUN.
256.e3 C.A. Villanueva

Most patients had more than one indication for surgery:
all had T1/2 more than 30 min, six had less than 40% dif-
ferential renal function (DRF), two had urosepsis, and three
had worsening HUN.
The average preoperative ureteral diameter was 1.6 cm
(range 0.9e3 cm). HUN was grade 4 in six of the nine (66%)
patients and grade 3 in three of the nine (33%) patients.
Five patients had obstructed megaureters and four had
ectopic ureters diagnosed on cystoscopy. All the patients
had preoperative nuclear medicine scans (eight had MAG 3
and one had a dimercaptosuccinic acid scan) at a median age
of 57 days (range 42e139 days). All patients who had a MAG 3
had T1/2 of more than 30 min and three had plateau curves
(infinite drainage). Mean DRF was 38% (range 18e52%).
Median operative time was 156 min (range 99e178 min).
Ureteral tapering was not performed in the initial four
cases. The last five cases had ‘mini’ tapering. The initial
four cases were not tapered for fear of causing obstruction.
The last five cases were tapered because of the initial four
cases, two had PO VUR.
All patients had 3-month PO RUS, and seven of the nine
patients had a VCUG. VCUG was not recommended on the
last two patients based on the experience with previous
patients.
Two patients (#1,#2) had PO VUR grade 4e5 three
months after surgery. Patient #1 had a VCUG 1 year PO
showing resolution of the VUR. Patient #2 did not follow up
1 year PO for his VCUG but came to the clinic recently 4
years PO due to bowel and bladder incontinence. Because
he had been infection-free since surgery and had a normal
RUS, it was decided not to do a VCUG on him.
Four patients were not tapered:
 Two had no PO VUR;
 One had transitory reflux (resolved 1 year after surgery);
 One had VUR at 3 months PO and was not tested again
for VUR. He has been infection-free for 4 years after
surgery.
Five patients underwent ‘mini’ tapering:
 None had been diagnosed with VUR.
Eight patients had a significant improvement in the de-
gree of HUN; the RUS was unchanged in one (#7) patient.
This patient’s MAG 3 showed stable differential renal
function (38->36%) and improved T1/2 (>30 min -> 8 min).
Another patient had repeat MAG 3 because of recurrent
UTIs showing normal T1/2 and preserved differential renal
function (patient 5#)
One patient (#5) with a normal PO VCUG, MAG 3, and
resolved HUN had a few PO febrile UTIs. At the last follow-
up, she had been doing well, infection free off prophylaxis
for more than 1 year.
Another patient (#6) developed new contralateral grade
2 VUR but remains asymptomatic off antibiotic prophylaxis.
At a median time from surgery of 44 months, there have
been no reoperations, no other immediate or delayed
complications, and the incidence of PO symptomatic UTI or
ipsilateral VUR has been 1/9 (11%).
Voiding function
With regard to voiding function, six patients were suc-
cessfully potty trained, two are younger than 2 years, and
one has bowel and bladder incontinence at the age of 4
years. This last patient had a RUS 4 years PO, showing
normal thickness bladder with 59 mL and no hydro-
nephrosis. He has remained infection-free since surgery.
Because he lacks no bowel control and has no radiologic
evidence of neurogenic bladder, it was assumed that his
surgery was not the cause of his voiding dysfunction and the
patient was referred for behavioral evaluation.
Discussion
MER has been the only surgery needed for this consecutive
cohort of infants younger than 6 months. Most patients
were potty trained, normally suggesting no effects on
voiding function at 44-month median follow-up.
Peters et al. [2], Greenfield et al. [3], Liu et at [4], Jude
et al. [5], and the data presented here demonstrate that
ureteral reimplantation in infancy can be performed with
similar success rates and complication rates as a ureteral
reimplantation performed after 1 year of age. None of the
patients has required a reoperation, and only one devel-
oped a PO febrile UTI or ipsilateral VUR.
Peters et al. [2], Greenfield et al. [3], Liu et at [4], and
Jude et al. [5] all used an intravesical approach. MER offers

Table 1 Patient characteristics.

# Sex Age Presentation Diagnosis Side %DRF T1/2 0Z No Drainage SFU Distal ureter
Months 0Zprenatal 1ZEctopic 1Z >30 min 2ZDMSA grade diameter (cm)
UTD 1ZUrosepsis ureter 2ZPOM
1 M 2 0 1 R 18.2 0 3 0.88
2 M 4 0 1 R 32 2 4 1.9
3 M 2 0 2 L 25 0 4 1
4 F 3 1 1 L 36 0 4 1.3
5 F 3 1 1 L 51 1 3 1.62
6 F 3 0 2 R 51 1 4 3
7 M 2 0 2 L 38 1 4 1.2
8 M 5 0 2 R 39 1 3 1.8
9 F 5 0 2 L 52 1 4 1.5
‘Mini’ extravesical reimplant
the advantages of decreased cystotomy size compared with
an intravesical approach and access to both megaureters
and ectopic ureters. It is a reproducible operation very
familiar to most pediatric urologists. Extravesical ureteral
reimplantation can be performed in less operative time
with less PO discomfort and shorter hospital stay compared
with intravesical reimplants, with both techniques being
equally effective [9].
Although recommended by the current guidelines [11],
the alternatives to immediate reconstruction are associ-
ated with much higher rates of complications and reoper-
ations. For example, treatment by stent placement without
reimplantation was associated with 32% chance of stent
migration, stone formation or infection, 46% need for sub-
sequent surgery, and 10% of kidney loss [12]. Cutaneous
ureterostomy is associated with 100% reoperation rate
necessary to undivert the patient, 40% incidence of PO
reflux after the definitive repair, 40% incidence of febrile
UTI while awaiting undiversion, and a 31% incidence of
reoperations after undiversion [1].
Fears regarding the development of bladder dysfunction
are also not supported by the literature. Neither de Kort
et al. [6], Ooi et al. [7], Upadhyah et al. [13] nor de Jong
et al. [14]found a detrimental effect on bladder function
from a ureteral reimplant performed during infancy.
Restricting reimplantation to one side also minimizes the
risk of nerve damage. The one patient in this series who has
not been potty trained at the age of 4 years does not appear
to have a neurogenic bladder because he has not had UTIs
and has a normal RUS; this patient also has bowel inconti-
nence and is currently been evaluated for developmental
delay, suggesting that the urinary incontinence is most
likely due to nonesurgery-related causes.
Some patients presenting with urosepsis and distal ure-
teral obstruction are not candidates for immediate recon-
struction. Most can be treated with antibiotics and then
surgery can be performed once the infection has been
cleared. For those not responding to antibiotics, a percu-
taneous nephrostomy tube can be placed, with definitive
surgery a few weeks later.
Ureteral tapering added the need for a second proced-
ure under general anesthesia to remove the stent. Clini-
cally, both tapered and non-tapered patients did well, with
neither group requiring a second surgery for obstruction or
VUR. Radiologically, two of the four non-tapered reimplants
developed high-grade reflux, which seems to have been
transitory and inconsequential. However, both patients
with PO VUR were circumcised boys, a group which tends to
do well with VUR. Despite the small numbers, the experi-
ence brings up the question that has been raised in an
earlier study [15] of whether ureteral tapering is always
necessary for obstructed megaureters.
This study was limited by a low number of patients. Need
for a reimplant in infants younger than 6 months is rare, and
thus, the accumulation of large number of patients outside
the context of a multicenter study would require several
years. By itself, this study would not constitute sufficient
evidence to change practice, but analyzed in the context of
the other four studies mentioned previously [2e5], it so-
lidifies the case in favor of immediate reconstruction.
Analysis of current literature does not support tempo-
rizing maneuvers as the treatment of choice for most
256.e4
patients with obstruction. Based on the relative advantages
and risks, MER should be considered for infants with
obstructed distal ureters.
Conclusions
For babies younger than 6 months in need of surgery for
obstructed distal ureters, MER appears to be a feasible and
effective option, associated with reduced morbidity and
reoperation rate compared with the alternatives.
A prospective multi-institutional study on EUR during
infancy is currently underway and still recruiting for more
centers (NCT02419339 clinicaltrials.gov).
Author statements
Ethical approval
This study was approved by the institutional review board
(605-16-EP).
Funding
None declared.
Competing interests
No conflict of interest.
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Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jpurol.2019.01.004.
C.A. Villanueva
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