0022-5347/01/1652-0552/0

THE JOURNAL OF UROLOGY® Vol. 165, 552–554, February 2001

Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.

IPSILATERAL URETEROURETEROSTOMY FOR THE TREATMENT OF

VESICOURETERAL REFLUX OR OBSTRUCTION ASSOCIATED WITH
COMPLETE URETERAL DUPLICATION
DAVID B. LASHLEY, IRENE M. McALEER AND GEORGE W. KAPLAN
From the Division of Urology, University of California, San Diego and Children’s Hospital and Health Center, San Diego, California

ABSTRACT

Purpose: We reviewed our experience with ureteroureterostomy as definitive treatment for

vesicoureteral reflux or obstruction associated with ureteral duplication to determine the efficacy
and morbidity of this procedure and identify factors that affect outcome.
Materials and Methods: We performed a total of 100 ureteroureterostomies in 94 children with
an average age of 28 months during the 23-year period ending May 1999. Four patients (4
kidneys) failed to return for postoperative evaluation. Followup was 2.5 to 206 months (mean 33).
Indications for surgery were vesicoureteral reflux in 53 cases, obstructing ureterocele in 19,
ureterocele with upper pole reflux in 4, an ectopic obstructed upper pole ureter in 18 and other
in 2. In 23 kidneys ureteroureterostomy was combined with reimplantation of the recipient
ureter. Surgery was considered successful when postoperative imaging revealed no reflux or
obstruction and a patent ureteroureterostomy anastomosis.
Results: Ureteroureterostomy with or without ureteroneocystostomy was successful for treat-
ing 94% of kidneys, including 51 of 53 with reflux, 21 of 23 (91%) with ureterocele and 17 of 18
(94%) with an ectopic obstructed upper pole ureter. Significant ureteral size disparity, defined as
a donor ureter diameter greater than 2-fold that of the recipient ureter, was noted in 69 kidneys.
The most common complication (13 patients) was prolonged output from the Penrose drain.
However, this complication did not result in a failed procedure in any case.
Conclusions: Ipsilateral ureteroureterostomy is safe and efficacious for treating abnormalities
associated with ureteral duplication. A significant discrepancy in ureteral size does not preclude
ureteroureterostomy.
KEY WORDS: ureter, abnormalities, vesico-ureteral reflux, ureterocele

When vesicoureteral reflux and distal ureteral obstruction
associated with complete ureteral duplication require surgi-
cal intervention, they may be managed by common sheath
ureteroneocystostomy, reimplantation of only 1 of 2 duplex
ureters, pyeloureterostomy or heminephroureterectomy.1, 2 If
1 or each duplicated ureter is dilated, ureteral tapering or
folding may also be necessary.3 In 1928 Foley initially de-
scribed ureteroureterostomy for treating problems associated
with ureteral duplication but it was not until 1965 that
Buchtel revived interest in the procedure.4, 5 We have previ-
ously reported favorable results with this technique in 20
patients6 and we have performed ureteroureterostomy as
definitive treatment for reflux or obstruction associated with
ureteral duplication in an additional 74. We review our ex-
perience to determine further the efficacy and morbidity of
this procedure and identify factors that affect outcome.
MATERIALS AND METHODS
We performed a total of 100 ureteroureterostomies in 28
males and 66 females 1 week to 38 years old (mean and
median age 28 and 24 months, respectively) during the 23-
year period ending May 1999. All except 1 operation were
performed in children 11 years or younger. Four patients (4
kidneys) who failed to return for postoperative evaluation
were excluded from study. Followup was 2.5 to 206 months
(mean 33, median 17). All renal units had complete ureteral
duplication except 1 with a distal common stem. Indications
for surgery in the 90 patients (96 kidneys) who returned for
followup were vesicoureteral reflux into the upper (6), lower
Accepted for publication September 29, 2000.
552
(43), and upper and lower (4) pole moieties; obstructing ure-
terocele with (8) and without (11) lower pole reflux; uretero-
cele with upper pole reflux (4); an ectopic obstructed upper
pole ureter (18); an obstructed common stem (1); and an
upper pole ureterocutaneous fistula (1). In 23 kidneys uret-
eroureterostomy was combined with reimplantation of the
recipient ureter and in 9 patients contralateral single system
ureteroneocystostomy was also performed. Surgery was done
on the left and right sides, and bilaterally in 58, 26 and 6
cases, respectively.
Our technique of ureteroureterostomy has been described
previously.6 After retrograde ureteropyelography confirmed
the anatomy a ureteral catheter was usually placed in the
recipient ureter to aid in intraoperative identification. The
duplex ureters were exposed extravesically with a Pfannen-
stiel or Gibson incision. The ureters were separated from
each other about 3 cm. from the bladder wall and proximal to
their common sheath to avoid disrupting their common blood
supply. The donor ureter was transected obliquely and its
distal stump was ligated. Longitudinal ureterotomy was
made in the recipient ureter to match the diameter of the
donor ureter. The anastomosis, which was not routinely
stented, was formed with interrupted 5-zero chromic suture
and a Penrose drain was placed near the anastomosis. Chil-
dren with a history of vesicoureteral reflux of the recipient
ureter or significant contralateral reflux also underwent si-
multaneous intravesical ureteroneocystostomy. Those with
ureterocele who also had ipsilateral lower pole reflux or who
required contralateral ureteroneocystostomy underwent con-
comitant ureterocele marsupialization by a previously de-
scribed technique.7
 IPSILATERAL URETEROURETEROSTOMY FOR ABNORMALITIES IN URETERAL DUPLICATION
Postoperatively imaging included voiding cystourethrogra-
phy to evaluate absent reflux and excretory urography (IVP),
mercaptoacetyltriglycine renal scan or renal ultrasound for
assessing the resolution of obstruction. Thereafter ultra-
sound was performed periodically to assess new or worsening
hydronephrosis, or hydroureter. Surgery was considered suc-
cessful when postoperative imaging revealed no reflux or
obstruction and a patient ureteroureterostomy anastomosis.
The effects of operative indication, ureteral lumen size dis-
parity and postoperative complications on outcome were ex-
amined.
RESULTS
Overall ureteroureterostomy was successful for treating
94% of the kidneys, including 51 of 53 (96%) with reflux, 21
of 23 (91%) with ureterocele, 17 of 18 (94%) with an ectopic
obstructed upper pole ureter, 1 (100%) with a ureterocutane-
ous fistula and 0 of 1 (0%) with an obstructed common stem
ureter. Failure was manifested by ureteroureterostomy ob-
struction in 3 cases, reflux in 2 and a nondraining ureteral
stump in 1. One of the 3 failures due to obstruction was
functional in nature. This problem developed in a child with
grade IV lower pole reflux who underwent lower-to-upper
pole ureteroureterostomy. Postoperatively IVP revealed
baseline lower pole hydronephrosis and a normal upper pole.
One year later IVP and subsequent antegrade nephrostogra-
phy were performed due to recurrent urinary tract infections.
The anastomosis was patent but the lower pole ureter pro-
lapsed with filling, causing obstruction of each ureter. The
kidney was salvaged with lower-to-upper pole pyeloureteros-
tomy. Two children had true anastomotic obstruction that
was discovered on routine postoperative imaging 3 months
after surgery in 1, while the other presented 2 years after
surgery with pyelonephritis. Each child had undergone
upper-to-lower pole ureteroureterostomies for obstructed up-
per pole moieties, including 1 with associated ureterocele.
Repeat ureteroureterostomy was performed successfully in 1
patient but 1 was lost to followup after a surgical procedure
was done elsewhere.
In 23 kidneys ureteroureterostomy was combined with re-
implantation of the recipient ureter and an additional 9
ureteroneocystostomies were performed on refluxing con-
tralateral ureters. Postoperatively a boy and a girl had vesi-
coureteral reflux. The boy, who was reported on previously,
had partial duplication and obstruction of the common ure-
ter.6 He underwent simultaneous ureteroureterostomy and
ipsilateral tapered reimplantation. The girl underwent
lower-to-upper pole ureteroureterostomy for lower pole re-
flux. Postoperatively voiding cystourethrography revealed
reflux in each case. Subsequently ureteroneocystostomy per-
formed distal to the ureteroureterostomy anastomosis 14
months after the original operation was successful in the boy,
while the girl recently underwent ureteral reimplantation 26
months after the original operation. Postoperative imaging
has yet to be performed.
Another girl with an obstructed ureterocele but without
reflux underwent upper-to-lower pole ureteroureterostomy
without cystotomy. Postoperatively recurrent urinary tract
infections developed and we noted a 4 cm. poorly draining
upper pole ureteral stump and new onset contralateral re-
flux. The stump was excised and bilateral ureteroneocystos-
tomies were performed. Postoperatively IVP and voiding cys-
tourethrography were normal but recurrent cystitis persists.
Ureteral size was documented in the operative report for
85 kidneys in this series. A significant ureteral size disparity,
defined as a donor ureter diameter greater than 2 or more
times that of the recipient ureter, was noted in 69 kidneys.
There was a significant discrepancy in ureteral size in 4 of
the 6 failed ureteroureterostomies.
In the postoperative period 22 complications developed in
553
19 patients who underwent ureteroureterostomy. The most
common complication was prolonged output from the Penrose
drain in 13 cases for an average of 15 days (range 7 to 31).
Simultaneous ureteroneocystostomy did not affect the inci-
dence or duration of prolonged drainage. Output was pro-
longed for 11 and 16 days in 3 of the 21 patients (14%, 23
kidneys) who underwent simultaneous ipsilateral ureteron-
eocystostomy and in 10 of the other 69 (14%, 73 kidneys),
respectively. Drainage stopped spontaneously in all except 2
patients, of whom 1 required temporary percutaneous ne-
phrostomy. In the other case the Penrose drain was removed
3 days after surgery and a urinoma subsequently developed,
requiring placement of percutaneous drain near the anasto-
mosis. Drainage ceased 31 days after surgery. Other postop-
erative complications included fever of unknown origin and
blood transfusion in 2 patients each, and ileus, drain sewn in
wound, gastroenteritis, febrile urinary tract infection and
pneumonia in 1 each. None of the 22 complications developed
in the 6 patients with a failed procedure.
We did not note an iatrogenic ureteroureteral yo-yo reflux8
phenomenon in any of our patients in the postoperative pe-
riod. Other than the 6 failed procedures there were no cases
of recurrent infection, flank pain or worsening hydronephro-
sis. If yo-yo reflux occurred, it did not cause any abnormality
on postoperative imaging or result in any clinical problems.
Average hospitalization in our cases was 4.6 days. However,
during the last 2 study years average hospital stay decreased
to 3 days.
DISCUSSION
Ureteral duplication anomaly occurs in 0.75% of the gen-
eral population and, as our study confirms, it is more com-
mon in females. Vesicoureteral reflux usually involving the
lower pole ureter is the most common abnormality associated
with ureteral duplication.9 In addition, the upper pole ureter
may be ectopic or have an associated ureterocele. Either
anomaly may cause reflux or more commonly obstruction. We
have observed that ipsilateral ureteroureterostomy is a
highly successful operation with low morbidity when associ-
ated reflux or obstruction leads to the recommendation for
surgery children with duplicated ureters.6
In this study there was a 94% overall success rate for
ureteroureterostomy for treating 96 kidneys with duplicated
ureters. There was no difference in success whether the pro-
cedure was done for reflux or obstruction. Neither prolonged
urinary leakage from the anastomosis nor significant ure-
teral size disparity was predictive of surgical failure. Others
have reported smaller series with similar results (table
1).2, 6, 10 –14
The incidence of prolonged drain output remained constant
throughout the 23 years of this study, which may partially be
due to our formation of an interrupted rather than a running
suture anastomosis. We did not note that this complication
was significantly morbid because it did not influence outcome
and home care was not difficult, especially since half of the
children were still in diapers. In most cases the Penrose tube
began to drain urine soon after surgery, while the Foley
catheter was still in place. In these children the catheter was
TABLE 1. Ipsilateral ureteroureterostomy
No. Reflux/No.
References No. Pts.
Obstruction
No. Failures
Huisman et al6 20 8/12 1
Duthoy et al10 12 12/0 0
Amar11 16 13/3 0
Bockrath et al12 13 13/2 1
Ahmed and Boucaut2 19 19/0 0
Jelloul and Valayer13 19 19/0 0
Bieri et al14 24 20/4 1
Totals 123 3 (2%)
554 IPSILATERAL URETEROURETEROSTOMY FOR ABNORMALITIES IN URETERAL DUPLICATION
removed at the usual time. Depending on continence status
and the amount of output they were discharged home with an
absorbent dressing or urostomy bag over the drain site.
Concerns have been raised about performing this proce-
dure when significant ureteral size disparity is present, de-
fined in this report as a donor ureter diameter greater than
2 or more times that of the recipient ureter.5, 13, 15 Ureter-
oureterostomy was successful in 65 of the 69 kidneys (94%)
with significant size discrepancy in this series. Our experi-
ence suggests that if recipient ureterotomy length is equal to
the diameter of the larger donor ureter, ureteral size dispar-
ity has no influence on the surgical outcome. Other theoret-
ical concerns include the creation of iatrogenic ureter-
oureteral yo-yo reflux8, 16, 17 and recurrent infections from
residual ureteral stumps.18 –20 Our experience is similar to
that of others in that only 1 patient required a subsequent
operation to remove a ureteral stump and no postoperative
problems were attributable to yo-yo reflux.13, 14 While we
believe that yo-yo reflux exists, in our practice we have not
observed that it causes symptoms after ipsilateral ureter-
oureterostomy.
The main advantages of ureteroureterostomy are technical
ease and decreased morbidity compared to the flank or trans-
vesical approach. Ureteral stenting is not necessary and
avoiding cystotomy provides a more comfortable recovery
with a shorter hospital stay. In addition, the recipient ureter,
which usually had no associated pathology, was not subjected
to the risk of obstruction or iatrogenic reflux from common
sheath ureteroneocystomy.
Common sheath ureteroneocystostomy is commonly done
to repair abnormalities associated with ureteral duplication.
The reported success rate is similar to that of ipsilateral
ureteroureterostomy (table 2).1–3, 15, 19, 21, 22 The majority of
failures reported were due to persistent reflux. However,
postoperative obstruction has also been reported.22 The main
concern regarding this technique is the technical difficulty of
dealing with large dilated ureters, especially when creating a
submucosal tunnel of adequate length. Weinstein et al re-
ported a series of 6 children with megaureter who underwent
simultaneous ureteral tapering and common sheath reim-
plantation.3 No ureteral obstruction was noted but 1 patient
had persistent reflux postoperatively for an overall success
rate of 83%.
Four children in our series had vesicoureteral reflux into
the upper and lower pole moieties of a single kidney. In all 4
cases the lower pole ureter was larger than the upper pole
ureter and, thus, lower-to-upper pole ureteroureterostomies
were performed with simultaneous reimplantation of the up-
per pole ureters. The diameter of the upper and lower pole
ureters was such that tapering at least 1 would have been
required for common sheath ureteroneocystostomy. We per-
form common sheath ureteroneocystostomy when a trans-
vesical approach is warranted, the ureters have an almost
equal diameter and ureteral tapering is not indicated. Hemi-
nephroureterectomy is another option often used to manage
TABLE 2. Common sheath ureteral reimplantation
No. Reflux/No.
References No. Pts. No. Failures
Obstruction
Fehrenbaker et al19 13 13/0 2 coureteral reflux and ureteral duplication in children. J Urol,
Belman et al15 14 14/0 1 107: 862, 1972
Barrett et al21 44 44/0 2 20. Belman, A. B.: Editorial comment. J Urol, 129: 544, 1983
Ahmed and Boucaut2 42 42/0 0
Lee et al22 23 23/0 2
Ellsworth et al1 48 48/0 1 solutions in surgical treatment of 100 consecutive ureteral
Weinstein et al3 6 4/2 1 duplications in children. J Urol, 114: 126, 1975
Totals 190 9 (5%)
pathological conditions related to duplicated ureters. We re-
serve this option for children who have no or minimal func-
tion of the diseased renal moiety on dimercapto-succinic acid
renal scan.
CONCLUSIONS
Ipsilateral ureteroureterostomy is safe and efficacious for
treating vesicoureteral reflux or distal ureteral obstruction
associated with ureteral duplication. Prolonged drainage
from the anastomosis does not affect the success of the pro-
cedure. Anastomotic obstruction is uncommon. A significant
discrepancy in ureteral size does not preclude ureteroureter-
ostomy.
REFERENCES
1. Ellsworth, P. I., Lim, D. J., Walker, R. D. et al: Common sheath
reimplantation yields excellent results in the treatment of
vesicoureteral reflux in duplicated collecting systems. J Urol,
155: 1407, 1996
2. Ahmed, S. and Boucaut, H. A.: Vesicoureteral reflux in complete
ureteral duplication: surgical options. J Urol, 140: 1092, 1988
3. Weinstein, A. J., Bauer, S. B., Retik, A. B. et al: The surgical
management of megaureters in duplex systems: the efficacy of
ureteral tapering and common sheath reimplantation. J Urol,
139: 328, 1988
4. Foley, F. E. B.: Uretero-ureterostomy: as applied to obstructions
of the duplicated upper urinary tract. J Urol, 20: 109, 1928
5. Buchtel, H. A.: Uretero-ureterostomy. J Urol, 93: 153, 1965
6. Huisman, T. K., Kaplan, G. W., Brock, W. A. et al: Ipsilateral
ureteroureterostomy and pyeloureterostomy: a review of 15
years of experience with 25 patients. J Urol, 138: 1207, 1987
7. Scherz, H. C., Kaplan, G. W., Packer, M. G. et al: Ectopic uret-
eroceles: surgical management with preservation of conti-
nence: review of 60 cases. J Urol, 142: 538, 1989
8. Lenaghan, D.: Bifid ureters in children: an anatomical, physio-
logical and clinical study. J Urol, 87: 808, 1962
9. Kaplan, W. E., Nasrallah, P. and King, L. R.: Reflux in complete
duplication in children. J Urol, 120: 220, 1978
10. Duthoy, E. J., Soucheray, J. A. and McGroarty, B. J.: Reflux in
duplicated ureters. J Urol, 118: 826, 1977
11. Amar, A. D.: Ipsilateral ureteroureterostomy for single ureteral
disease in patients with ureteral duplication: a review of 8
years of experience with 16 patients. J Urol, 119: 472, 1978
12. Bockrath, J. M., Maizels, M. and Firlit, C. F.: The use of lower
ipsilateral ureteroureterostomy to treat vesicoureteral reflux
or obstruction in children with duplex ureters. J Urol, 129:
543, 1983
13. Jelloul, L. and Valayer, J.: Ureteroureteral anastomosis in the
treatment of reflux associated with ureteral duplication.
J Urol, 157: 1863, 1997
14. Bieri, M., Smith, C. K., Smith, A. Y. et al: Ipsilateral ureterouret-
erostomy for single ureteral reflux or obstruction in a dupli-
cate system. J Urol, 159: 1016, 1998
15. Belman, A. B., Filmer, R. B. and King, L. R.: Surgical manage-
ment of duplication of the collecting system. J Urol, 112: 316,
1974
16. Boyarsky, S., Labay, P. and Lenaghan, D.: Transureteroureter-
ostomy, bifid ureters and ureteral dyskinesia. J Urol, 99: 156,
1968
17. Campbell, J. E.: Ureteral peristalsis in duplex renal collecting
systems. AJR Am J Roentgenol, 99: 577, 1967
18. Lytton, B., Weiss, R. M. and Berneike, R. R.: Ipsilateral ureter-
oureterostomy in the management of vesicoureteral reflux in
duplication of upper urinary tract. J Urol, 105: 507, 1971
19. Fehrenbaker, L. G., Kelalis, P. P. and Stickler, G. B.: Vesi-
21. Barrett, D. M., Malek, R. S. and Kelalis, P. P.: Problems and
22. Lee, P. H., Diamond, D. A., Duffy, P. G. et al: Duplex reflux: a
study of 105 children. J Urol, 146: 657, 1991