FOCUS ON DETAILS
Surgery Illustrated – Focus on Details
BJUI BJU INTERNATIONAL
Tapering of the Megaureter
Raimund Stein, Peter Rubenwolf, Christopher Ziesel and Joachim W. Thüroff *
Division of Paediatric Urology, *Department of Urology, Johannes Gutenberg University of Mainz, Medical School,
Germany
ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com
KEYWORDS
megaureter, surgery, ureteric tailoring,
ureteric reimplantation
INTRODUCTION
The term ‘megaureter’ describes a grossly
dilated ureter comprising a wide spectrum
of anomalies associated with an increased
ureteric diameter [1,2]. Cussen [3] showed in
autopsy studies, that a normal ureter in
children usually has a diameter of <5 mm.
Hellstrom et al. [4] were able to confirm this
finding by reviewing IVUs performed in
children for a range of indications. A normal
ureter in infancy and childhood generally
does not exceed 6 mm in diameter. The
current definition of megaureter is a ureter
with a diameter of >6 mm. In 1976, during
a joint meeting of pediatric urology societies
in Philadelphia, a nomenclature and
classification of megaureters was agreed
upon and later reported and presented by
Smith et al. [5] and Stephens [6]. This ‘ABC
classification’ included the refluxing ureter
(A), the obstructed ureter (B) and the
non-refluxing, non-obstructed ureter (C). A
megaureter is commonly referred to as
primary megaureter, when the dilatation is
due to an intrinsic pathology of the ureter
and secondary when the dilatation is the
result of a dysfunction of the bladder or the
outlet. In 1980, King [7] added as fourth
group the refluxing, obstructed megaureter,
keeping the primary and secondary
subclassifications.
Today, the overwhelming majority of
megaureters are detected pre- or
© 2 0 1 2 B J U I N T E R N A T I O N A L | 11 0 , 1 8 4 3 – 1 8 4 7 | doi:10.1111/j.1464-410X.2012.11676.x
postnatally, are usually asymptomatic and
can be treated conservatively in most cases.
Indications for surgical correction comprise
decreasing ipsilateral split renal function,
febrile UTIs (despite antibiotic prophylaxis
– break-through infections), pain or ureteric
calculi and/or lack of improvement or even
an deterioration of dilatation during
follow-up examinations [1,8].
If surgical intervention is indicated, ureteric
reimplantation can be performed by either
intravesical, extravesical or combined
intra- and extravesical techniques [2]. Using
the ‘Psoas Hitch’ technique, ureteric tailoring
is not required in most cases when a less
dilated middle third of the ureter is
mobilised and reimplanted into an
appropriate submucosal tunnel. For ureters
that are too dilated for a tunnelled
reimplantation, two options for remodelling
the ureter exist. Firstly plication, infolding or
imbrication can be performed in moderately
dilated ureters according to the ‘Starr’ or the
‘Kalicinski’ techniques, which, however, do
not reduce the bulk of ureteric tissue,
which is the limiting factor for bladder
reimplantation by submucosal tunnel
formation [9,10]. Secondary excisional
tapering as described by Hendren [11],
which is especially useful for severely
dilated or thick-walled ureters. Hendren
used Allis clamps to mark the redundant
ureter tissue while preserving the blood
supply to the remaining ureter wall. Placing
the clamps and achieving a straight cut
line can be challenging. We describe herein
the use of a straight vascular clamp (De
Bakey vascular clamp), which facilitates
resection of redundant ureteric tissue for
tapering.
PLANNING AND PREPARATION
INDICATIONS
• Symptomatic primary obstructive
megaureter (resulting in febrile UTIs/pain/
ureteric calculi).
• Decrease of ipsilateral split renal function.
• High-grade refluxing megaureter.
• Increasing dilatation during follow-up
examinations.
SPECIFIC INSTRUMENTS AND MATERIALS
• Optical loupes (2.5–3.5, 50-cm focal
length).
• Small Langenbeck retractors.
• 120 ° DeBakey vascular clamp.
• 6/0 or 7/0 Glyconate monofilament
absorbable sutures for ureteric
reimplantation and tapering (e.g. Monosyn®
or Monocryl®).
• 4/0 and 5/0 Poly-p-dioxanone
monofilament absorbable (e.g. Monoplus® or
PDS®) for bladder closure.
• 4/0 or 5/0 Glyconate or polyglytone
monofilament rapidly absorbable sutures for
fixation of stents, cystostomy (e.g. Monosyn
Quick® or Caprosyn®).
• 3/0 Poly-p-dioxanone monofilament
absorbable (e.g. Monoplus or PDS) for
bladder fixation at the psoas muscle.
• 8 F polyurethane/polypropylene ureteric
stent.
• 10 F pigtail cystostomy catheter.
PATIENT PREPARATION
• Voiding cystourethrogram (exclude reflux).
• Kidney, ureter and bladder
ultrasonography (diameter of the ureter, and
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dilatation of the renal pelvis/calices
– exclusion of ureterocele).
• Mercaptoacetyltriglycine (MAG3)
clearance (split renal function and nuclide
extraction in response to furosemide).
• MRI, if other imaging is not conclusive.
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PATIENT POSITIONING
Supine position slightly overstretched (15 °).
The patient is placed supine on the table
with about 15 ° of overextension. A Foley
transurethral catheter is inserted, which
must provide intraoperative access for filling
the bladder during the operation.
© 2012 BJU INTERNATIONAL
 FOCUS ON DETAILS

TAPERING OF THE URETER

Figure 1

The ureter is exposed through a

suprainguinal extraperitoneal incision. The
ureter can be identified by its typical
peristalsis, which however may be reduced
in grossly dilated ureters. The diameter can
appear larger than the adjunct bowel. The
megaureter typically exhibits a thickened
wall surrounded by dense fibrous tissue. The
ureter is mobilised from the bladder
cranially with careful preservation of
longitudinal vessels. The dense connective
tissue bands, which attach the ureteric
meanders to each other, are dissected
carefully. Upon completion of mobilisation,
the ureter should have a straight course
from the renal pelvis down to the bladder
without relevant kinks remaining. In most
cases, the ureter is less dilated in its middle
and cranial thirds and can after mobilisation
be reimplanted without tailoring. The ureter
is transected at its entry into the detrusor
and the distal stump is ligated. However, if
after transection and decompression the
ureter still has a too large a diameter in its
middle third, which does not allow bladder
reimplantation by submucosal tunnel
formation, tailoring of the ureter is
performed.

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STEIN ET AL.

Figure 2

a+b. A 6 or 8 F ureteric stent is inserted into

the ureter. Insertion should be smooth and
easy, assuring that there is no remaining
kinking in the ureter.

After mobilisation and straightening of the

ureter, the abundant ureteric length is
resected. Only the distal part of the
remaining ureter, which is to be reimplanted
into the bladder, and a few centimetres
above must be tapered. In smaller children,
the tailored ureteric segment should be
≈10 cm in length. The ureter is stretched by
a distal stay suture and the ureteric stent is
manipulated in the circumferential segment
of the ureter, which contains the
longitudinal vessels is to be preserved. The
120 ° vascular clamp is placed onto the
redundant ureteric tissue against the
ureteric stent, so that the longitudinal
vessels are preserved. Using a No. 21 knife,
which is guided along the straight branches
of the De Bakey clamp, the redundant
ureteric tissue is removed in a straight cut.
a
b, The longitudinal margins of the ureter are
sutured with a single row running and
locked 6/0 glyconate monofilament
absorbable suture (e.g. Monosyn or
Monocryl). For ureteric reimplantation using
the psoas hitch technique, a 3–5 cm long
submucosal bladder tunnel is created, the
ureter is pulled through the tunnel and the
psoas hitch sutures are tied. After bladder
fixation, the ureter should enter the bladder
in a straight course without kinking at the
entry. At this stage it is sometimes necessary
to increase the tunnel width of the entry
between the detrusor and mucosa by gentle
dissection with scissors. The ureteric stent
and a 10 F pigtail cystostomy catheter are b
brought out through the bladder wall and
secured with rapidly absorbable 4/0
polyglytone suture. A 16 F gravity drain is
placed alongside the tapered ureter at the
entry of the bladder.

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POSTOPERATIVE MANAGEMENT
Medication. Antibiotics (i.e. cephalosporines)
are started at the time of surgery and are
continued as long as the stent is in situ.
The paraureteric drain is removed on day 1
or 2. As soon as the urine is virtually clear,
the transurethral Foley catheter is removed.
Depending on the difficulty of the
procedure, the ureteric stent is removed
between day 7 and 10 (in complicated cases
on day 10). After removal of the stent, the
cystostomy is clamped and the patient
starts to void. The upper tract is checked by
ultrasonography on the next day (in adults,
upper tract imaging is achieved by IVU). The
cystostomy catheter is removed, when the
bladder is emptied without residual urine.
SURGEON TO SURGEON
After a megaureter has undergone tapering
and ureteric reimplantation, almost
invariably some degree of dilation of the
upper tract persists postoperatively, which
gradually decreases within 3–6 months.
However, grossly dilated and clubbed calyces
may never return to a normal size. If there
is any concern of persistent obstruction, a
MAG3 clearance with furosemide should be
obtained. In children, antibiotic prophylaxis
should be continued as long as there is
© 2012 BJU INTERNATIONAL
increased dilatation of the upper tract as
compared with preoperatively.
In patients with symptomatic postoperative
ureteric obstruction, a JJ-catheter is placed
antegradely through a percutaneous
nephrostomy tract and left for 3 months.
In case of persistent obstruction from
implantation stenosis, ‘redo’ surgery may be
considered but not earlier than 3 months
after the initial procedure.
REFERENCES
1 Khoury A, Bägli D. Reflux and
Megaureters. In Wein AJ, Kavoussi L,
Novick AC, Partin AW, Peters C eds.
Campbell-Walsh Urology, 9th edn.
Philadelphia: Saunders Elsevier, 2007:
3423–81
2 Joseph DB. Ureterovesical Junction
Anomalies: Megaureters. In Gearhart JP,
Rink RC, Mouriquand PD eds. Pediatric
Urology, 2nd edn. Philadelphia: Saunders
Elsevier, 2010: 272–82
3 Cussen LJ. The structure of the normal
human ureter in infancy and childhood.
A quantitative study of the muscular
and elastic tissue. Invest Urol 1967; 5:
179–94
4 Hellstrom M, Hjalmas K, Jacobsson B,
Jodal U, Oden A. Normal ureteral
diameter in infancy and childhood. Acta
Radiol Diagn (Stockh) 1985; 26: 433–9
FOCUS ON DETAILS
5 Smith ED, Cussen LJ, Glenn JF et al.
Report of the working party to establish
an international nomenclature for the
large ureter. Birth Defects Orig Artic Ser
1977; 13: 3–8
6 Stephens F. The ABC of megaureters. In
Bergsman DJ ed. Birth Defects Articles
Series. National Foundation 1977. p. 1–8
7 King LR. Megaloureter: definition,
diagnosis and management. J Urol 1980;
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8 Beetz R, Fisch M, Hohenfellner R.
Primäre und skundärerMegaureteren.
In Stein R, Beetz R, Thüroff J eds.
Kinderurologie in Klinik und Praxis, 3rd
edn. Stuttgart: Thieme, 2011: 332–46
9 Starr A. Ureteral plication. A new
concept in ureteral tailoring for
megaureter. Invest Urol 1979; 17:
153–8
10 Kalicinski ZH, Kansy J, Kotarbinska B,
Joszt W. Surgery of megaureters
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J Pediatr Surg 1977; 12: 183–8
11 Hendren WH. Operative repair of
megaureter in children. J Urol 1969;
101: 491–507
Correspondence: Raimund Stein, Dept. of
Urology, University Medical Center,
Langenbeck Str. 1, D-55131 Mainz, Germany.
e-mail: raimund.stein@unimedizin-mainz.de
Abbreviation: MAG3,
mercaptoacetyltriglycine.
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