Megaureter is a relatively common congenital urinary tract anomaly; obstructed non-refluxing megaureter is one variant. Initial management is conservative, with operative intervention reserved for symptomatic cases (recurrent pyelonephritis, pain, increasing dilatation or worsening renal function). Surgical options include cutaneous ureterostomy, stenting, endoscopic dilatation, endoureterotomy and ureteral dilatation. Concerns exist regarding ureteral reimplantation in the first year of life due to size discrepancy between ureter and bladder, and the need for extensive dissection and tailoring if the ureter is dilated / tortuous. Consequently, cutaneous ureterostomy has often been favoured (this also poses risks in terms of the urinary stoma). In 2014, Kaefer described a technique of distal ureteral dismemberment and direct (refluxing) reimplantation into the bladder. It was a temporising strategy with subsequent formal reimplantation. Alyami et al. report the outcomes from a modified, non-dismembered, side to side refluxing ureterocystostomy (UC) as a simple and perhaps permanent method of internal diversion. A retrospective review of UC procedures (from four centres) between January 2012 and January 2017 was undertaken. Twenty-seven patients underwent UC on 29 renal units (two bilateral) for obstructive non-refluxing megaureter. Mean operating room time was 93.3±21 minutes. Average length of stay was 0.5 days (range 0-2). After a mean follow-up of 34.3±15.4 months (range 6-58), 23 of 27 (85%) remain infection free. Four experienced febrile urinary tract infections – two underwent ipsilateral ureteral reimplantation, one a circumcision and the other continued conservative management. Most patients showed improved dilatation (86%) or stable hydroureteronephrosis with improved drainage on MAG3 (14%). Antibiotic prophylaxis was discontinued in 17 patients (16 males, 14 circumcised) at mean follow-up of 21 months (all infection free). The authors acknowledge ureteral decompression may not be as effective with a refluxing anastomosis and cases may ultimately require tailoring. However, UC offers a simple and quick internal diversion that is minimally invasive and potentially definitive. Kaefer’s contribution has unsurprisingly generated a healthy amount of debate – indeed at the recent Society for Fetal Urology (SFU) Fall Meeting in Montreal, he stated that he had been accused “of setting the discipline of paediatric urology back by 20 years” by one of his mentors. I have performed a number of these procedures during my paediatric urology training in Southampton and undertook my first as a consultant in Cambridge in September (obstructed upper moiety ureter with ectopic insertion). Time will tell for both myself and others if the results are as long-lasting. 

Side-to-side refluxing nondismembered ureterocystotomy: a novel strategy to address obstructed megaureters in children.
Alyami FA, Koyle MA, Bowlin PR, et al.
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Neil Featherstone

Cambridge University Hospitals NHS Foundation Trust (Addenbrookes Hospital).

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