Non-obstructive, non-refluxing uretero-colonic anastomosis by colonic sero-muscular excision and extra mural peri-ureteric wrap - A new technique in 17 children.

Introduction: Uretero-enteric anastomosis with concomitant neobladder/augmentation/conduit becomes necessary when the bladder is unavailable or unfit for reimplantation or the ureters are short after high diversion or resection of lower ureteric pathology. Aiming to prevent both obstruction and reflux, we report a novel technique of sero-muscle denuded extra mural uretero-colic anastomosis.

Operative Technique: (Fig 1) The ureter was brought through the colonic mesentery. An adjacent zone of colon "abcd" was chosen to receive the ureter and colonic sero-muscular layer was excised from this zone. The ureter was placed on the raw area and uretero-colic anastomosis was done (a-d).The edges of the sero-muscular layer (ab and cd) were sutured over the ureter to complete a submucosal tunnel. The augmentation/neo bladder was completed such that the implanted ureter lay within it between two regions of re-configured bowel, this adding to the anti-reflux mechanism created by the extra mural peri-ureteric wrap.

Aim: Surgical audit of this technique.

Materials And Methods: 17 children (exstrophy - 8, ectopic ureter with bladder agenesis/hypoplasia - 3, prune belly - 2, neurogenic bladder -2, eosinophilic cystitis -1 and posterior urethral valve -1) underwent colonic implantation of 23 ureters while 6 ureters were drained via a trans uretero-ureterostomy into the reimplanted ureter. Nine augmentation, seven neo bladders and one sigmoid conduit was performed. The colon was available for ureteric re-implant in all patients.

Results: Pre-operatively 21 had hydroureteronephrosis. The bladder was agenetic/hypoplastic, small and fibrosed or poorly compliant. Eleven ureters had been diverted. Post operatively (mean follow up - 3.4 years) 16 of 30 renal units were normal, 11 had mild and three had moderate residual hydronephrosis, with no new hydronephrosis. Cystogram showed no reflux in 14 children and unilateral reflux in three (one re-diverted). Of 29 renal units drained directly or via trans uretero-ureterostomy by the uretero-colic reimplantation, none are obstructed, 26 have no vesico-ureteric reflux while three (10%) have reflux.

Discussion: We report results comparable to other extra mural techniques into the bowel, mainly from adult literature. Pediatric refluxing ureters are often large megaureters with or without preliminary diversions. The technique described avoids obstruction although having a slightly higher incidence of recurrent VUR. The ureters with recurrent reflux were massively dilated preoperatively and showed decrease in ureteric diameter postoperatively. The wrap, made for a larger ureter could have become too roomy and allowed reflux.

Conclusion: This technique of non refluxing non obstructive uretero-colonic anastomosis has proven useful in selected situations.