This is a surgical procedure that is meant to correct bladder-ureteral reflux (pathological pathway of urine from the bladder to the ureter to the kidney) or the ureteral stenosis of the terminal tract.
All cases of reflux with recurrent urinary tract infection should be undergoing surgery if no endoscopic correction method has been performed or failed. In cases of moderate reflux, clinically asymptomatic, a waiting treatment may be selected.
All ureteral stenosis of the terminal tract can be treated with this method as an alternative to endourological treatment.
Surgical correction consists in disassembling the ureter-bladder junction (normal link between the ureter and bladder) and its reconstruction by replanting the ureter into the bladder. The intervention is often done in children because reflux is a congenital defect; Adult use is more commonly for stenosis correction.
Surgical incision is performed in the hypogastrium (lower part of the abdomen); Can be vertical (between pube and navel) or transverse (immediately above the pube, in the form of concave smile). An extravesical technique (rarely used today) or a transvesical technique can be practiced, i.e. with the direct opening of the bladder (the most commonly used today).
The extravesical procedure involves incision of the bladder wall from the outside with release of the ureter up to its bladder outlet (Lich technique). The bladder wall (detrusor muscle) located below the normal course of the ureter is engraved for about 3 cm and removed from the mucous membrane (inner layer of the bladder wall) to form a sort of channel. The ureter is positioned in that channel and the bladder wall is closed above it to form a longer intravesical course of the ureter. This technique is based on the assumption that the creation of an intravesical tunnel to allow a longer ureter flow within the bladder wall is the key element in the prevention of reflux.
The paradigm of transversal techniques is Politano-Leadbetter’s intervention. It involves a transverse cutaneous incision (Pfannenstiel) and a clear bladder opening. The intravesical ureter is released from its connections with the bladder wall, is “extracted” from the bladder and reintegrated into it through an opening created in the bladder wall above the old orifice; At this point the bladder mucosa between the new opening and the location of the “old” ureteral orifice is opened to create a submucosal tunnel where the ureter “re-entered” higher into the bladder is deposited. The bladder mucosa above the ureter is closed and a new ureteral orifice is reconstructed in the position where the previous one at the beginning of the operation was located, after closing the outer layers of the bladder wall. Thus, the ureteral orifice in the bladder is positioned approximately at the same position as the previous one, but the ureter has a longer course along the bladder itself, a key element for the prevention of reflux.
It should be noted that there are many other “ureteral replanting” techniques and that in cases of greatly dilated ureter it may be necessary to model a ureter prior to its bladder replantation. Another supportive surgical operation in particular situations is the so-called “poas-hitch”, i.e. bladder suture at the poas muscle, placed laterally and superiorly to the bladder. This technique serves to gain space when the ureter is short, and also ensures greater bladder fixation, in practice allowing for greater fixation of the ureteral intramural bladder portion. At the end of the surgery, a pelvic drain is left which is removed in the first postoperative days as needed (amount and quality of the product).
Postoperative treatment involves the use of antibiotics, being in bed for a few days and the removal of ureteral catheters (called “tutors”) with which the ureter has been channelized, in a period of time that is variable but still oscillates around the 2 weeks (although more modernly they tends to be removed earlier).
These ureteral catheters come out on the outside of the body and great care must be taken to prevent their tearing or damage. Their functionality must be protected with hydration and, if necessary, washing from the outside.
Preparation for intervention:
The intervention does not require a special preparation outside of that standard one (fasting from the midnight, trichotomy, antibiotic prophylaxis, a slag-free diet in previous days and evacuating enema). There is no need of particularly sophisticated logistics structures (if not good nursing facilities for baby patients).
Duration of intervention:
The intervention has a variable duration of 1 h and 30 min to 3 h depending on the local situation. Ureteral stenosis, especially if recurrent, is the intervention that takes longer.
Type and duration of hospitalization:
Hospitalization is carried out in an ordinary course (inpatient) with an average stay of about 3 weeks. The element that binds the patient to hospitalization is the removal of ureteral catheters. In the case where an autostatic ureteral catheter (double J stent) is left in place, the stay can be reduced to about 10 days but needs a short re-entry (outpatient) after approximately one month for the endoscopic removal of the stent.
Literature describes successful percentages (meaning no reflux recurrence) that reach up to 95%.
The main benefit to endoscopic technique is to have a higher success rate.
The disadvantages are the generic ones of an open surgery, with long stay/recovery time, possibility of wound infection, and so on.
no one in particular. Cohen’s technique does not allow the possibility of practicing ureteroscopy with rigid instruments in the future.
The most specific complication is considered to be the stenosis of the reconstructed junction, which may be caused by a technical error or a ureteral vascularization injury such as ischemising the terminal ureter itself. As in any surgery, other possible complications are those related to bleeding, infection, and lesion of nearby organs located in the pelvis.
It is good practice to take antibiotic therapy even after removal of the catheters, if necessary up to one month later.
How to behave in case of complications arising after discharge:
In the case of colic and fever pain it is advisable to refer to the urological center.
The cardinal examination of postoperative check is the cystourethrography that highlights if the reflux is still present. It should be practiced at least 3-4 months after surgery. Renal ultrasound should be performed one month after surgery and repeated after 3 months. Urography can be practiced at 6 months.
Also useful are periodic urine examination with culture (every 2 months). The patient must be followed for a few years and even though technically successful, his renal function should always be periodically monitored.