SURGICAL STRATEGIES IN CHILDREN WITH DUPLEX SYSTEMS

In a retrospective study, 413 children and 446 surgical procedures rel ated to a duplex system were examined. The objective was to analyze cr itically our treatment strategies fur double kidneys and associated an omalies in children. Vesicorenal reflux was the presenting condition. In 143 renal units (RU) with good function in both poles, primary anti reflux surgery was performed according to the Lich-Gregoir (RU = 101) or Psoas-Hitch technique (RU = 42). Of the intravesical ureteroceles, 24 RU were treated by endoscopic incision/resection and 22 RU were res ected and the ureter reimplanted. A heminephroureterectomy was perform ed in 152 RU due to a nonfunctioning pole. In half of the cases, the r emaining ureter was reimplanted. 22 nonfunctioning double kidneys were removed, other surgical procedures (e.g. cystostomy, nephostomy) were performed in 83 RU. Complications requiring surgical revision occurre d in 7% of the cases after antireflux surgery (3% secondary nephrouret erectomy, 4% reimplantations). A secondary procedure was required in 4 /19 RU in which endoscopic incision of a ureterocele was performed. A high complication rate was observed following heminephrectomy alone in cases with intravesical orifices for both ureters (54% reflux, 13% ob struction). In cases in which antireflux reimplantation of the remaini ng ureter was performed following heminephroureterectomy of a nonfunct ioning pole, urinary tract infection occurred in 7%, reflux in 3%, and obstruction in 4%. After heminephrectomy alone in cases with an extra vesical ectopic ureter, urinary tract infections were seen in 8% and r eflux in 4%. For the surgical repair of reflux, the common implantatio n of both ureters from the refluxive duplex system has proved effectiv e. The endoscopic incision of the ureterocele alone should be performe d only prophylactically or as an emergency procedure for decompression . A heminephrectomy is justified in the presence of a nonfunctioning p ole with an extravesical ectopic ureter. This should be combined with an antireflux procedure if both orifices are intravesical.