Retrospective study to determine the short-term outcomes of a modified pneumovesical Glenn–Anderson procedure for treating primary obstructing megaureter. Issue 5 (October 2015) - Liu, Xing
Summary: Introduction: Primary obstructive ureter (POM) is an upper urinary tract malformation in children. Transvesicoscopic ureteral reimplantation 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 Glenn–Anderson 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 months–14 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. 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 Glenn–Anderson technique advances the ureteral orifice distal to the trigone near the bladder neck and allows 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 Glenn–Anderson 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 disadvantage from the standpoint of ureterovesical fistula. Conclusions: These preliminary results indicate that this modified transvesicoscopic ureteral implantation is an effective procedure with minimal morbidity. 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).