Surgical strategies in children with duplex systems

In a retrospective study, 413 children and 446 surgical procedures related to duplex kidneys were examined. The objective was to analyse critically ou r treatment strategies for double systems and associated anomalies in child ren. Vesicorenal reflux was the presenting condition. In 143 renal units (RU's) with a good function in both pores, primary antireflux surgery was performe d according to the Lich-Gregoir (RU = 101) or Psoas-Hitch technique (RU = 4 2). Of the intravesical ureteroceles, 24 RU's were treated by endoscopic in cision/resection and 22 RU's were resected and the ureter reimplanted. A he minephroureterectomy was performed in 152 RU's due to a nonfunctioning pole . In half of the cases, the remaining ureter was reimplanted. 22 nonfunctio ning double kidneys were removed, other surgical procedures (e.g, cystostom y, nephrostomy) were performed in 83 RU's. Complications requiring surgical revision occurred in 7 % of the cases afte r antireflux surgery (3 % secondary nephroureterectomy, 4 % reimplantations ). A secondary procedure was required in 14/19 RU's in which endoscopic inc ision of a ureterocele was performed. A high complication rate was observed following heminephrectomy alone in cases with intravesical orifices for bo th ureters (54 % reflux, 13 % obstruction). In cases in which an anti-reflu x reimplantation of the remaining ureter was performed following heminephro ureterectomy of a nonfunctioning pole, urinary tract infection occurred in 7 %, reflux in 3 %, and obstruction in 4 %. After heminephrectomy alone in cases with an extravesical ectopic ureter, urinary tract infections were se en in 8 % and reflux in 4 %. For the surgical repair of reflux, the common implantation of both ureters from the refluxive duplex system has proved effective. The endoscopic incis ion or resection of the ureterocele alone should be performed only prophyta dically or as an emergency produce for decompression. A heminephrectomy is justified in the presence of a nonfunctioning pole with an extravesical ect opic ureter. This should be combined with an antireflux procedure if both o rifices are intravesical.