Laparoscopy as the investigation and treatment of choice for urinary incontinence caused by small ‘invisible’ dysplastic kidneys with infrasphincteric ureteric ectopia

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Abstract
To report our experience of using laparoscopy for the accurate location and simultaneous removal of small dysplastic kidneys with ectopic ureteric insertion causing urinary incontinence and that were not detected by conventional imaging modalities. Seven girls (mean age 7.9 years, range 3.5-13) presented with urinary leakage occurring between normal voids. Imaging studies including ultrasonography, renal scintigraphy, intravenous urography, computed tomography and/or magnetic resonance imaging in six of the seven patients revealed a single normal functioning kidney, but failed to detect the contralateral nonfunctioning dysplastic kidney. All patients were examined under anaesthesia, followed by transperitoneal laparoscopy for the simultaneous localization and removal of the dysplastic kidneys under the same setting. Laparoscopy in all seven patients revealed a small dysplastic kidney that could always be easily located by first finding the draining ureter over the iliac vessels and then following it upwards. Four dysplastic kidneys were found in the renal fossa (two left, two right). One kidney was found at the left iliac fossa just above the pelvic brim, one at the left lumbar region, and the other at the right iliac fossa. Laparoscopic nephroureterectomy was successful in all seven girls and the patients were discharged 48 h after surgery. The follow-up (mean 2.7 years, range 3 months-5.4 years) showed excellent cosmetic results and all the patients have remained completely dry. In patients with a classical picture of urinary incontinence caused by infrasphincteric ureteric ectopia associated with a small nonfunctioning kidney, video-laparoscopy, with its magnifying effect, can reliably confirm the diagnosis, locate the dysplastic kidney and allow its removal in the same setting. We propose that laparoscopy should be considered the investigation and treatment of choice in such patients, and should be undertaken without delay even if the dysplastic kidney or the ectopic ureteric orifice cannot be identified with all other conventional means.