|Year : 2017 | Volume
| Issue : 3 | Page : 158-160
Primary ureterocalicostomy in a child: Operative steps
Rajendra B Nerli1, K Shankar1, Vishal Kadeli1, Shridhar C Ghagane2
1 Department of Urology, KLE Academy of Higher Education and Research (Deemed-to-be-University), JN Medical College Campus; Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India
2 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, India
|Date of Web Publication||14-Feb-2018|
Rajendra B Nerli
Department of Urology, KLE Academy of Higher Education and Research (Deemed-to-be-University), JN Medical College Campus, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi
Source of Support: None, Conflict of Interest: None
Ureterocalicostomy completely excludes the renal pelvis and the stenotic ureteropelvic junction (UPJ) area and establishes urinary drainage from the lower calyx directly into the ureter. Technically, a successful ureterocalicostomy includes a generous spatulation of a healthy ureter, adequate excision of lower pole renal parenchyma, and a tension-free, precise, mucosa-to-mucosa uretero-caliceal anastomosis. We report a case of primary UPJ obstruction in a child with a small renal pelvis surrounded by multiple branches of renal vessels treated with primary ureterocalicostomy.
Keywords: Hydronephrosis, pelvi-ureteric junction obstruction, pyeloplasty, ureterocalicostomy
|How to cite this article:|
Nerli RB, Shankar K, Kadeli V, Ghagane SC. Primary ureterocalicostomy in a child: Operative steps. J Sci Soc 2017;44:158-60
| Introduction|| |
Anderson–Hynes pyeloplasty is widely regarded as the operation of choice for the routine management of ureteropelvic junction (UPJ) obstruction,, irrespective of whether it is performed through open, laparoscopic, or robotic-assisted laparoscopic means. However, at times, it may be necessary to consider alternative techniques to achieve reliable drainage. Such situations include recurrent UPJ obstruction  and UPJ obstruction associated with anatomical anomalies, notably horseshoe kidney  and traumatic damage to the UPJ or proximal ureter.
The use of ureterocalicostomy (anastomosis between the ureter and a dependent calyx) was first described in 1947 and attributed to Neuwirt. Though commonly performed in adults, there have been relatively few reports on the use of ureterocalicostomy in the pediatric age group. Radford et al. evaluated the outcome of ureterocalicostomy as both a primary and salvage procedure within a single center over a 12-year period. Thirteen children (mean age: 9.3 years) underwent ureterocalicostomy (primary procedure in four children) with a mean follow-up of 2.6 (0.3–7.0) years. Twelve children (92%) experienced a good functional outcome following ureterocalicostomy, as defined by reduced dilatation and improved drainage on postoperative ultrasonography and/or isotope imaging. One child (8%) developed symptomatic anastomotic obstruction 5 months after primary ureterocalicostomy for obstruction in a horseshoe kidney. Surgical revision was successful, with good drainage, preservation of differential function, and relief of symptoms on further follow-up to 3 years. We report on a case of UPJ obstruction in a male child treated by primary ureterocalicostomy, operative technique, and operative steps.
| Case Report|| |
An 11-year-old male child presented to the pediatric urology outpatient department with complaints of pain in abdomen. The child also had severe mental retardation (mental age: 3 years, 6 months). Imaging procedures including abdominal sonography, computed tomography (CT) of the abdomen, and radio-isotope scans confirmed the diagnosis of left-sided UPJ obstruction. CT revealed a hugely dilated kidney with a very small pelvis [Figure 1]. This led to the decision to perform open repair.
|Figure 1: Computed tomography showing a dilated left pelvicalyceal system, a small renal pelvis, and plenty of soft tissue around the renal pelvis and ureteropelvic junction|
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The child was explored with a left lumbar incision. The left ureter was dissected and followed up to the renal pelvis. The pelvis was small and was surrounded by the branches of the renal artery and veins. The renal pelvis and UPJ could not be dissected free of the vessels without traumatizing them. The lower pole calyx was thinned out and it was decided to perform primary ureterocalicostomy.
The technique of ureterocalicostomy comprised of disconnection of the ureter from the renal pelvis and identification of the most dependent part of the lower pole calyx by instrumentation within the collecting system [Figure 2]. The risk of fibrotic stenosis was minimized by ensuring that renal parenchyma was generously excised to expose a sizeable area of the lower pole calyx. A tension-free anastomosis between the spatulated proximal ureter and opened calyx was then created using a 6-0 polydioxanone suture, with care being taken to ensure continuity between the two urothelial surfaces. A double-J (DJ) ureteric stent was placed within the pelvis prior to completion of the anastomosis.
|Figure 2: (a) Anatomical features favoring ureterocalicostomy in our case: thinned cortex overlying dilated lower pole calyx and small renal pelvis surrounded by multiple branches of renal vessels. Difficulty in ensuring reliable dependent drainage by conventional pyeloplasty. (b) Steps of ureterocalicostomy. Exposure of lower pole calyx and excision of cortical tissue adjacent to the site of anastomosis. Tension-free anastomosis ensuring continuity of calyceal and ureteric urothelia. Closure of renal pelvis at the site of the original pelvi-ureteric junction|
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The postoperative period was uneventful. The DJ was removed 6 weeks later and a retrograde ureteropyelogram done at the same time revealed adequate drainage [Figure 3].
| Discussion|| |
Neuwirt employed the technique of ureterocalicostomy in a grossly hydronephrotic kidney with thinned cortex. Subsequent efforts by other surgeons to reproduce Neuwirt's outcome met with varying success. Mollard and Braun  described the successful use of ureterocalicostomy as a primary procedure in 14 children, of whom seven had horseshoe kidneys. It was Mesrobian and Kelalis  who were subsequently instrumental in popularizing the procedure and highlighting the key technical aspects of success, namely extensive excision of lower pole tissue to expose the calyx and a stented noncircumferential anastomosis, with care being taken to ensure continuity between the urothelial lining of the ureteric lumen and the luminal surface of the opened calyx. Mesrobian and Kelalis  reported the use of ureterocalicostomy for a range of indications in a series of 21 children ranging in age from 6 months to 17 years. Nineteen of these patients had a decrease or elimination of hydronephrosis. There were, however, two patients with postoperative complications requiring further surgical intervention: one requiring stent insertion for prolonged urinary drainage with anastomotic leakage and the other requiring treatment of a Candida perinephric abscess causing ureterovesical junction obstruction on the ipsilateral side to the ureterocalicostomy.
Sarhan et al. recently reported their experience in ten children, with an overall success rate (as evident on isotope renography) of 80% at a mean follow-up of 18 months. Two patients in their series (20%) required nephrectomy for recurrent obstruction and loss of function. Ureterocalicostomy is definitely a safe choice for the management of most cases of recurrent UPJ obstruction as a result of scarring and stenosis at the site of a previous pyeloplasty. In addition to its role as a salvage procedure, ureterocalicostomy also offers distinct advantages over the conventional Anderson–Hynes pyeloplasty for the primary surgical management of UPJ obstruction, notably for obstruction secondary to complicating anatomical anomalies of the kidney, such as horseshoe kidney. In this anomaly, the aberrant vasculature and the interconnecting isthmus of parenchyma may make it difficult to create an anastomosis capable of ensuring dependent drainage. Other anatomical barriers to adequate drainage include an intrarenal pelvis and upper ureteric stenosis, for which ureterocalicostomy has been successfully employed in the management of these rare causes of upper tract obstruction.
Ureterocalicostomy is a versatile operation, and in addition to the indications described above, its use has also been reported for the management of renal avulsion as a result of trauma. Other reported indications include renal transplant salvage  and renal-sparing surgery in transitional cell carcinoma.,, The series recently reported by Sarhan et al. includes the use of ureterocalicostomy in four children who had either sustained iatrogenic injury to the proximal ureter or iatrogenic avulsion of the ureter.
| Conclusion|| |
Ureterocalicostomy is a versatile and reliable means of relieving obstruction for a variety of indications in children, including horseshoe kidney, recurrent UPJ obstruction, and gross UPJ obstruction with unfavorable anatomy. Approximation of ureteric and caliceal urothelium and excision of renal parenchyma in the proximity to the anastomosis are the key steps for securing a satisfactory outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Valla JS, Breaud J, Griffin SJ, Sautot-Vial N, Beretta F, Guana R, et al
. Retroperitoneoscopic vs. open dismembered pyeloplasty for ureteropelvic junction obstruction in children. J Pediatr Urol 2009;5:368-73.
Ravish IR, Nerli RB, Reddy MN, Amarkhed SS. Laparoscopic pyeloplasty compared with open pyeloplasty in children. J Endourol 2007;21:897-902.
Sarhan OM, Helmy TE, Hafez AT, Ghali AM, Mohsen T, Dawaba ME, et al
. Ureterocalyceal anastomosis in children: Is it still indicated? J Pediatr Urol 2009;5:78-81.
Mollard P, Braun P. Primary ureterocalycostomy for severe hydronephrosis in children. J Pediatr Surg 1980;15:87-91.
Kaouk JH, Gill IS: Laparoscopic reconstructive urology. J Urol 2003;170:1070.
Mesrobian HG, Kelalis PP. Ureterocalicostomy: Indications and results in 21 patients. J Urol 1989;142:1285-7.
Nerli RB, Magdum PV, Pathade A, Mallikarjun RN, Pingale ND, Ghagane SC, et al
. Primary ureterocalicostomy in children. Indian J Health Sci Biomed Res. 2017;10:221-4.
Nerli RB, Pingale ND, Shankar K, Musale A, and Ghagane S. Primary Ureterocalicostomy for a Patient with Giant Hydronephrosis. International Journal of Scientific Research. 2016;5:96-97.
Moloney GE. Avulsion of the renal pelvis treated by ureterocalycostomy. Br J Urol 1970;42:519-21.
Jarowenko MV, Flechner SM. Recipient ureterocalycostomy in a renal allograft: Case report of a transplant salvage. J Urol 1985;133:844-5.
Selli C, Rizzo M, Moroni F, Dedola G, Amorosi A. Ureterocalicostomy in the treatment of pyeloplasty failures. Urol Int 1992;48:274-7.
[Figure 1], [Figure 2], [Figure 3]