Surgical Treatment of the Massively Dilated Ureter in Children. Part II. Management by Primary Reconstruction

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Abstract
Treatment of the massively dilated ureter is one of the major therapeutic challenges facing the pediatric urologist. When conservative measures, such as treatment of infection or relief of obstruction, fail or are likely to fail, surgical treatment must be directed at the ureteral dilatation itself. These circumstances were encountered in 244 children with 366 massively dilated ureters during a 10 yr period. In evaluating the surgical management of the massively dilated ureter in children a retrospective analysis of primary ureteral tailoring and/or preliminary nephrostomy and subsequent reconstruction in 131 children with 171 massively dilated ureters was done. In these instances sepsis, azotemia and ureteral tortuosity and redundancy were not significant enough to indicate long-term non-intubated diversion. Transvesical and extravesical tailoring procedures were evaluated. Of those in whom preliminary nephrostomy was applied ureteral dilatation decreased to such an extent that non-tailored reimplantation was performed in more than 25%. Initial upper tract tailoring, although not recommended by others, was done with uniform success. Subsequent upper tract tailoring was required in only 3% of those who initially underwent lower ureteral reconstruction. The over-all success rate of these primary reconstructive procedures was 87% by all parameters. Additional surgical procedures in selected initial failures have resulted in a final success rate of 90%. Of those unsuccessful reconstructions a significant number were secondary to acquired hypotonic bladder after extensive perivesical dissection in patients who had undergone multiple suprapubic procedures. It is for this reason that, when applicable, the transvesical approach was preferred.