Hypothesis / aims of study
Conventional treatment of ectopic ureter is reimplantation. However, in some case of ectopic ureter - unilateral ectopic ureter (UEU), subsequent malformation of the bladder neck may result in postoperative persistent incontinence and ureteric reimplantation alone may not solve the urological symptoms. This unusual scenario has been described in literature in association of bilateral single system ectopic ureters, but persistent incontinence following surgical management of UEU with ureteral opening at or distal to bladder neck in girls have not been clearly addressed in literature.
Study design, materials and methods
Twenty three female children operated for UEU between January 2009 to May 2018 were evaluated after getting Institutional approval. History including presenting complaints and other relevant symptoms were noted. The age and other basic demographic profile were recorded. Blood investigations including hemogram and renal function tests were done with other workup for pre anesthetic clearance. An ultrasonography was performed in all patients to rule out other anomalies. Further imaging in the form of Intravenous urography (IVU), Contrast enhanced CT (CECT) scan or Magnetic Resonance (MR) urography were done as required to establish a diagnosis on a case to case basis. An MCU (micturating cystourethrogram) was obtained in all patients to assess the bladder capacity and status of the bladder neck. A dynamic renal scan with L-ethyl cysteine was done in all patients to assess the drainage and split function of the ectopic system.
All patients underwent a urodynamic assessment preoperatively after obtaining ethical clearance. Patients were positioned in sitting position and 7 Fr pressure transducer catheter was inserted into the bladder to measure the intravesical pressure. Intraabdominal pressure was monitored via a rectal probe. The bladder was filled with saline at a rate of 5 to 10 ml/min depending on the weight of the patient to a volume of 150 ml or approximately half of the estimated functional capacity. The patient was then instructed to perform a Valsalva manoeuvre (expulsive effort against a closed glottis). The lowest increase in vesical pressure which results in sudden urinary leakage during this manoeuvre was considered as her ALPP.
Patients with a non functioning kidney/moiety or poorly functioning kidney/ moiety (<10% contribution of the global renal function) with ectopic ureteric insertion underwent nephroureterectomy and those patients with functioning system underwent reimplantation or ureterourterostomy.
All patients underwent cystoscopic examination prior to the definitive procedure. The cystoscopic findings were noted such as the bladder capacity, position of the ectopic ureteral orifice and the status of the bladder neck and trigone. Reimplantation was done in funcitoning moieties either by an open Cohen cross trigonal approach or by a laparoscopic extravesical approach over a double J stent.
The patients who had leak in the first 3 months of their postoperative period were managed conservatively with anticholinergics. The patients were then assessed again for persistent urinary incontinence after three months. The patients were divided into two groups depending on the status of incontinence. Group A included the patients who had persistent incontinence at 3 months and Group B included those patients who were completely dry at 3 months. Patients with very low ALPP (less than 30 cm H2O) were taken for bladder neck reconstruction procedure. Patients with more than 30 cm H2O ALPP were managed with conservative management with Kegels exercise and/or anticholinergics for a period of 6 weeks. Those who did not respond with conservative management during this time period were managed with bulking agents (Macroplastique®/Deflux®) at the bladder neck.
Statistical analysis was done using IBM® SPSS® v23.0. Mean and standard deviation were used for descriptive statistics. Chi-square test for categorical variables and Mann-Whitney U test for continous variables were used to test significance and p value < 0.05 was considered signficant.
Interpretation of results
Twenty three girls were operated for UEU with their ureteric orifice at or distal to bladder neck with mean age of 10.9 ± 3.15 yrs. Six underwent nephroureterectomy and 17 had reimplantation/ureteroureterostomy. Nine (39.1 %, Group A) girls had varying degree of incontinence postoperatively and 14 (60.9%, Group B) were dry. In group A, cystometrogram had demonstrated abdominal leak point pressure (ALPP) < 60 cm of water in 7 patients with mean ALPP of 43.9 ±16.15 while only one patient in Group B demonstrated leak. Preoperative ALPP predicted leak with 90% PPV. In Group A, 3 patients were managed with bladder neck reconstruction and two with bulking agents ( Macroplastique® or Deflux® ) and became completely dry. One improved with conservative management and three patients were lost to follow up.