Single distal ureter for ureterocystoplasty: A safe first choice tissue for bladder augmentation

Purpose: Recently, the use of ureter for bladder augmentation has gained wi de acceptance due to a lower complication rate compared to gastrointestinal segments. Unfortunately, the presence of a severely dilated urinary tract implicates loss of function of a renal unit which is often not demonstrated at diagnosis. Conversely, many patients present with I or both ureters mil dly dilated because of vesicoureteral reflux or functional obstruction. In these cases the use of a single distal ureter seems to be a good option. We report our experience and long-term followup with this subset of patients. Materials and Methods: Between December 1994 and November 1998, 17 females and 5 males 1.5 to 15.7 years old (mean age 7.2) with a low capacity, poorl y compliant bladder underwent ureterocystoplasty with a single distal dilat ed ureter. Diagnosis included myelomeningocele in 13 cases, central neuroge nic bladder in 3, neurogenic nonneurogenic bladder in 2, congenital spinal cord injury in 2, sacral agenesis in 1 and giant sacral teratoma in 1. All but 2 patients complained of recurrent febrile urinary tract infections. Va riable degrees of hydronephrosis were observed in all patients. Vesicourete ral reflux was detected in 14 patients and was bilateral in 3. Five patient s presented with chronic renal failure. Before surgery 19 patients were on clean intermittent catheterization and prophylactic antibiotics. The segmen ts of ureter used for augmentation ranged from 9 to 14 cm. long (mean II) a nd from 0.8 to 2.5 cm. in diameter (mean 1.3). The more distal piece of the ureter was kept unopened to preserve vascular supply. Simultaneous procedu res included transureteroureterostomy in all 22 patients, appendicovesicost omy in 10, bladder neck continence procedures in 4 and ureteroneocystostomy in 3. Clinical, radiological and urodynamic evaluation was done 6 months p ostoperatively and yearly thereafter. Results: Followup ranged from 12 to 60 months (mean 22). Of the patients 19 are dry on clean intermittent catheterization at 4-hour intervals and 6 ha ve had 9 symptomatic urinary tract infections. Hydronephrosis resolved in 1 4 patients, improved in 6 and remained unchanged in 2. On urodynamics media n increase in capacity less than 30 cm. pressure was 177% (range 11% to 560 %). When comparing capacity less than 30 cm. water to normal expected capac ity for age and weight, 50% of the cases reached or exceeded theoretical ca pacity while the rest reached 63% to 89% (mean 76%). Long-term complication s included persistent reflux in 1 case, deterioration of bladder function w ithout clinical impairment in 1 and spontaneous perforation of the ureteral patch in 1 requiring colocystoplasty. Conclusions: Although increase in bladder capacity is not always optimal wi th the use of a distal dilated ureter, it is good enough to ensure a good c linical outcome and allow an adequate catheterization interval with a low c omplication rate in the long term, thus avoiding use of a piece of gut or s tomach to perform bladder augmentation in nearly all patients.