YJPSU-59267; No of Pages 6

Journal of Pediatric Surgery xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Operative Techniques

Laparoscopic Extravesical Ureteral Reimplantation for Correction of

Primary and Secondary Megaureters: Preliminary Report of a New
Simplified Technique
Romy Gander a,⁎, Marino Asensio a, Gloria Fatou Royo a, Manuel López b,c
a
Department of Pediatric Surgery, Pediatric Urology and Renal Transplant Unit, University Hospital Vall d'Hebron, Passeig de la Vall d'Hebrón 119-129, 08035 Barcelona, Spain
b
Department of Pediatric Surgery, University Hospital Vall d'Hebron, Hospital Vall d'Hebron, Passeig de la Vall d'Hebrón 119-129, 08035 Barcelona, Spain
c
Universitat Autónoma de Barcelona, Hospital Vall d'Hebron, Passeig de la Vall d'Hebrón 119-129, 08035, Barcelona, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To describe a simplified surgical technique for the treatment of primary and secondary obstructed
Received 28 January 2019 megaureters in children by laparoscopic extravesical ureteral reimplantation (LEUR) and evaluate the short-
Received in revised form 7 May 2019 term outcomes.
Accepted 31 May 2019 Methods: Prospective study of children with primary and secondary megaureters treated at our institution be-
Available online xxxx
tween 2016 and 2018 by LEUR. A transperitoneal approach was used in all cases. The distal ureter was transected
at the level of the stenosis. Detrusor muscle fibers were divided to expose bladder mucosa. The distal ureter was
Key words:
Pediatrics
introduced into the bladder to create a valve-like mechanism. The ureter was fixed to the bladder mucosa by four
Laparoscopy stitches. We analyzed indications for surgery, complications and outcomes. Definition of success was relieved of
Obstructed megaureter obstruction and absence of VUR.
Laparoscopic ureteral reimplantation Results: Six patients with a mean age of 28.83 months (SD: 21.4) underwent LEUR. Indications for surgery were:
Minimally invasive surgery infection [2], obstruction [2], decrease in renal differential function [1] and increase in hydronephrosis [1]. There
were no intraoperative complications. Resolution of hydronephrosis, obstruction and VUR was achieved in all
cases. Mean follow-up was 13 months (SD: 6.67).
Conclusion: LEUR for the correction of primary and secondary megaureters by this new technique is safe. The
most important advantage is that this technique is simpler and more easily reproducible than conventional
LEUR. However, long-term follow-up is required.
Type of study: Prospective, observational.
Level of evidence: Level III.
© 2019 Elsevier Inc. All rights reserved.

Traditionally, open ureteral reimplantation has been the gold stan-
dard in the management of primary and secondary obstructive
megaureters (OM). Recently, successful outcomes using the laparo-
scopic extravesical ureteral reimplantation (LEUR) technique have
been reported [1–6].
We previously described our experience in LEUR with extracorpo-
real ureteral tapering for the primary obstructive megaureter in seven
patients with an overall resolution rate of 100% and without significant
complications [1]. However, this technique requires advanced
laparoscopic skills and is technically demanding even for the most
experienced surgeons. Therefore, in this study we aimed to describe a
novel simplified and reproducible surgical technique for megaureters
in children and evaluate the short-term outcomes.
⁎ Corresponding author at: Passeig de la Vall d'Hebron 119-139, 08032 Barcelona,
Spain.
E-mail address: rgander@vhebron.net (R. Gander).
1. Material and methods
We conducted a prospective study of children with primary and
secondary obstructive megaureters (OM) treated at our institution
between January 2016 and January 2018 by LEUR.
1.1. Data collection
Clinical data were collected prospectively. The evaluated parameters
were:
- Patients characteristics: age, weight, gender, time of diagnosis
(prenatal vs postnatal), type of megaureter, laterality
- Previous treatment: endoscopic injection for vesicoureteral reflux
(VUR), endoscopic balloon dilatation, temporary double-J stenting
- Indication for surgery: we considered as indication for surgery fe-
brile urinary tract infections (UTI), deteriorating differential renal

https://doi.org/10.1016/j.jpedsurg.2019.05.028
0022-3468/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: R. Gander, M. Asensio, G.F. Royo, et al., Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and
Secondary Megaureters: Prelimi..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.05.028
2 R. Gander et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
function (DRF) on serial scans, worsening dilatation, obstruction or
pain
- Preoperative imaging: preoperatively all patients underwent ultra-
sound, micturating cystourethrogram (MCUG) and diuretic reno-
gram (MAG-3)
- Operative factors: operative time, intraoperative complications,
need for conversion
- Postoperative complications: urinary leak, UTI.
- Postoperative imaging: ultrasound, MCUG and MAG-3 renogram
- Outcomes: resolution of obstruction, persistence or new VUR, need
for reintervention. The definition of success was the absence of ob-
struction, VUR and symptoms during follow-up.
1.2. Surgical technique
Under general anesthesia the patient was placed in a supine position
with slightly open legs. The operating table was placed in Trendelenburg
position and the monitor was positioned at the end of the table. The sur-
geon and assistant were standing at the head of the patient. A urinary
catheter was inserted at the beginning of the procedure in the sterile field.
LEUR was performed using a transperitoneal approach. Three ports
were used in all cases: one 5 mm 30° for the telescope at the level of
the umbilicus and two 3 mm ports at the left and right lower abdomen.
The peritoneum covering the ureter was incised at the level where it
crosses the iliac vessels, and the ureter was mobilized to achieve a
tension-free anastomosis. Starting the ureteral dissection more cranially
is usually not necessary and carries risk of ureteral devascularization.
As soon as the ureter was identified an umbilical tape was passed
around it precociously for traction; this helped to prevent ureteral in-
jury during dissection (Fig. 1). Alternatively, a vessel-loop can be used.
Traction by grasping directly the ureter with forceps should be avoided
to prevent ureteric injuries. During ureteral dissection, preservation of
generous periureteral adventitia and limited use of thermal energy are
crucial to avoid complications. When coagulation is necessary the use
of bipolar forceps is advisable. Once dissected, the distal ureter was
transected at the level of the stenosis. The ureteral stump was then
closed with an endoloop or a simple ligation only in case of preexisting
VUR; otherwise, we left it open (Fig. 2).
Then attention was turned to the implantation of the ureter into
the bladder. Using monopolar scissors the peritoneum was incised
to expose the detrusor. Two transabdominal traction sutures were
placed (Vycril 3/0) on both sides of the top of the bladder to allow ex-
posure of the ureterovesical junction and stabilize the anastomosis.
The bladder was then filled with saline or air and the superficial
detrusor was cauterized. The remaining muscle fibers were then di-
vided sharply with scissors from the apex of the detrusoromyotomy
towards the ureterovesical junction, until the mucosa was exposed
Fig. 1. The ureter is identified and an umbilical tape is passed around it precociously for traction.
Please cite this article as: R. Gander, M. Asensio, G.F. Royo, et al., Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and
Secondary Megaureters: Prelimi..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.05.028
(Fig. 3a). An incision length of 2–3 cm was sufficient since the
antireflux mechanism in this technique depends mainly on the
valvular mechanism of the ureteral segment introduced into
the bladder and does not rely entirely on the length of the tunnel.
All detrusor fibers were carefully opened to expose the bladder
mucosa. The bladder mucosa was then opened at the top of the
detrusoromyotomy and 1–1.5 cm of the distal ureter was introduced
into the bladder to create a valve-like mechanism similar to the
Shanfield technique (Fig. 3b) [7]. The ureter was fixed to the bladder
mucosa with four stitches of absorbable sutures (5/0 Vycril) at 6’, 12’,
3’ and 9’o clock (Fig. 3c). The detrusor was closed over the
reimplanted ureter with nonabsorbable sutures (3/0 Ethibond)
(Fig. 4). Neither a peritoneal drain nor ureteral stent was left in
place. No ureteral tailoring was performed.
1.3. Postoperative care
Children were started on oral liquids feeds within 2 h after surgery.
The urinary catheter was removed 12 h after surgery. Postoperative an-
algesia was performed with metamizole and paracetamol. Hospital dis-
charge occurred when the patient was pain free with oral analgesia,
normally between 24 and 48 h.
1.4. Follow-up
All patients underwent an ultrasound at 1, 3 and 6 months after sur-
gery, an MCUG at 3 months and MAG-3 at 6 months. Thereafter, in ab-
sence of VUR or obstruction follow-up was performed with ultrasound
every 6 months.
1.5. Statistics
Descriptive statistics were performed. Statistical analysis was per-
formed SPSS 15.0 software.
2. Theory
We describe our preliminary results of a novel simplified and repro-
ducible surgical technique for megaureters in children and evaluate the
short-term outcomes. However, a long-term follow-up is required and
safety and feasibility for this procedure in very young children and bilat-
eral cases have to be assessed.
3. Results
Six patients underwent LEUR (4 female, 2 male). The mean age at
surgery was 28.83 months (SD: 21.4).
 R. Gander et al. / Journal of Pediatric Surgery xxx (xxxx) xxx 3

Fig. 2. The distal ureter is transected at the level of the stenosis. The ureteral stump is then closed in this case with an endoloop.

Patients’ characteristics are listed in Table 1. Primary diagnosis was:
congenital obstructed-refluxing megaureter [3], obstruction post STING
procedure [1], duplex-system with ureterocele [1] and neurogenic blad-
der with increasing hydronephrosis after endoscopic injection for VUR
[1]. Indications for surgery were: infection [2], obstruction [3] and de-
crease in renal differential function [1]. All patients presented with se-
vere hydronephrosis and distal ureteral caliber N11 mm.
In all cases the procedure was completed laparoscopically. Median
operative time was 144 min (r: 120–160). There were no intraoperative
complications. No ureteral stents were used. Regarding postoperative
complications, two patients experienced immediate postoperative in-
fections (one immediately after surgery and the remaining presented
with fever 6 days after discharge). The first of them had a duplicated
system with an obstructed megaureter and ureterocele of the upper
pole and a high grade VUR to the lower pole. This patient had several in-
fections before surgery and experienced immediate postoperative fever
without other associated symptoms and positive urinary culture. The
second patient had a primary diagnosis of congenital obstructive-
refluxing megaureter. No urinary leakage occurred in the postoperative
period. Three patients experienced mild hematuria within the first
48–72 h without associated symptoms. None of the patients experi-
enced postoperative voiding dysfunction after removal of the urinary
catheter. Median hospital stay was 2 days (r: 1–4).
Interestingly, ultrasound at 1 month after surgery revealed increased
hydronephrosis without dilatation of the ureter in four of them (includ-
ing the two patients with infection), which disappeared in all of them at
3 months.
Postoperative MAG-3 renogram showed a nonobstructive pattern in
all patients and MCUG revealed absence of VUR in all. The procedure
was considered successful in all patients. With a mean follow-up of
15.83 months (SD: 6.67) (r: 7–23) all were asymptomatic.
4. Discussion
During the past decade, applications for laparoscopy in pediatric
urology expanded beginning with laparoscopic nephrectomy and
expanding to pyeloplasty; being currently the gold standard in both
procedures [8–11]. Recently, laparoscopy has been used with high suc-
cess rates for different, more complex, reconstructive urological proce-
dures [2,12,13]. Nevertheless, laparoscopic techniques requiring

Fig. 3. (a) Detrusoromyotomy is performed using sharp dissection. (b) Bladder mucosa is opened at the top of the tunnel. (c) 1–1.5 cm of the distal ureter is introduced into the bladder to
create a valve-like mechanism and the ureter is fixed to the bladder mucosa with four stitches of absorbable sutures at 6’, 12’, 3’ and 9’o clock.

Please cite this article as: R. Gander, M. Asensio, G.F. Royo, et al., Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and
Secondary Megaureters: Prelimi..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.05.028
4 R. Gander et al. / Journal of Pediatric Surgery xxx (xxxx) xxx

(6 days postop)
Complications

UTI

UTI
no

no

no

no
5 (owing to UTI)
Length of stay
(days)

2
1

2
time (min)
Operative

157

150
163

145

138

120
obstruction and UTI

Decrease in DRF
obstruction

obstruction
for surgery
Indication

UTI

UTI
Fig. 4. The detrusor is approximated over the reimplanted ureter with three interrupted

M: male; F: female; VUR: vesicoureteral reflux; UP: upper pole; LP: lower pole; DRF: differential renal function; US: ultrasound; MCUG: micturating cystourethrogram;
sutures.

Endoscopic balloon
Temporary double
procedures

dilatation
J stenting
Previous
intracorporeal suturing are technically demanding and linked to a
long learning curve, even for the most experienced surgeons.

no

no

no

no
With respect to ureteral reimplantation, different approaches
have demonstrated feasibility such as laparoscopy,

VUR (IV)

VUR (IV)
No VUR
VUR (I)

VUR (I)
MCUG
pneumovesicoscopy and robot-assisted technique. Although in open

no
surgery the Cohen cross-trigonal ureteral reimplantation has been
the most reliable and time-tested procedure, its vesicoscopic ap-
DRF- MAG-3

proach has not gained the expected popularity owing to long opera-
tive time, difficulty of the procedure and relatively long learning
25%

54%
49%

47%

35%

39%
curve [14]. Additionally, surgical correction of OM by this technique
is even more difficult, tailoring of the ureter demands more time
Diameter of

UP: 23 mm

UP: 18 mm
pelvis (US)

than simple reimplantation and this technique appears to have a

LP: 15 mm

LP: 14 mm
the renal

higher complication rate in young patients with small bladder capac-

26 mm
29 mm

14 mm

28 mm
ity [15].
Laparoscopic antireflux surgery (LAS) by the use of the
extravesical Lich–Gregoir technique was first reported in 1994 by
Diameter of
retrovesical
ureter (US)

Ehrlich but it was not until 2004 that it has become an accepted and
18 mm

14 mm
16 mm

12 mm

16 mm

11 mm
reproducible technique [16]. Based on the current literature, this ap-
proach has similar success rates to those of open surgery and the re-
sults are durable [2,12,13,17]. The advantages of the extravesical
right
Side

left

left
left

left

left

approach include reduced bladder spasm, no hematuria and less mor-

bidity because there is no need for anastomosis or ureteral stents
Congenital primary obstructive–

Congenital primary obstructive–

Incomplete ureteral duplication:
Obstruction post-STING for VUR

[17–20]. It was mainly the experience in the extravesical reimplanta-

tion technique that has served as the basis for the development of
LEUR for the OM. However, in contemporary practice the use of
secondary obstruction
refluxing megaureter

refluxing megaureter
Ureteral duplication:

Neurogenic bladder-
· VUR grade IV (LP)

LEUR for treatment of OM is still rare and the literature is sparse [3].
VUR grade IV (LP)
obstruction (UP)
ureterocele (UP)

Access, ureteral exposure, detrusor dissection and tunnel closure are

not only similar but almost identical in both procedures. The authors
Diagnosis

have previously described a large series of 117 children (representing

159 renal units) who underwent LAS with a mean resolution rate of
98.3% and a mean operative time of 96 min [13]. Later on, the authors
described their experience in LEUR for primary OM with extracorpo-
Presentation
Patients’ demographics and outcomes.

real ureteral tapering in seven patients with a resolution rate of 100%

postnatal
prenatal

prenatal

prenatal

prenatal

prenatal

[1]. However, in those patients the vesicoureteral anastomosis was

carried out by two continuous 6/0 PDS sutures, which are technically
demanding. Additionally, all required extravesical ureteral tailoring,
(months)

which in turn results in higher risk of postoperative urinary leakage

and the need for a JJ stent which has to be removed cystoscopically
Age

66
22

19

14

36
8

6 weeks later.
Gender

The key point of this novel, simplified technique, is that 1–1.5 cm of

Table 1

3M

6M

the distal ureter is introduced into the bladder to create a valve-like

No.

1F

2F

4F

5F

mechanism which prevents reflux. This technique is similar to the

Please cite this article as: R. Gander, M. Asensio, G.F. Royo, et al., Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and
Secondary Megaureters: Prelimi..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.05.028
 R. Gander et al. / Journal of Pediatric Surgery xxx (xxxx) xxx
Shanfield ureteral reimplantation principle, first described in 1972, but
with significant modifications [21]. This technique, mainly applied in
the field of kidney transplantation (KT), consists of fixing the spatulated
ureter to the bladder with a double armed U-stitch at least 2 cm beyond
the edge of the bladder opening [7,22]. In our technique the ureter is
then fixed to the bladder with only four stitches of absorbable sutures
(6’, 12’, 3’ and 9’o clock). This avoids not only the need for a complex
vesicoureteral anastomosis, but also the need of ureteral tailoring be-
cause the antireflux mechanism depends mainly on the valve-
mechanism of the ureteral tip introduced into the bladder and does not
rely entirely on the length of the submucosal tunnel. Recently also
Thompson et al. described an extrapolation of the Shanfield anastomosis
to Mitrofanoff channels and native ureteric reimplantations in 15 chil-
dren, 3 of them entirely undertaken laparoscopically [23]. Similar to
our results, their data suggest that the Shanfield anastomosis offers a
safe, robust and simple antireflux implantation technique without the
need to formally open the bladder. These authors also highlight another
important advantage of the technique which is that it overcomes the
problem of inadequate tunneling when the bladder template is deficient
[23].
Regarding other key points of the technique, it is extremely impor-
tant to handle the ureter with care during dissection. The authors sug-
gest to avoid grasping the ureter with forceps to prevent ureteric
injuries. Precociously, a vessel-loop or umbilical tape should be used
for traction [1,19,24]. Javali et al. described the use of a Rumel loop
(which is doubled over) and the two ends of the sling were clipped to-
gether with a metallic clip [17].
Most authors recommend a vertically oriented tunnel down to the
bladder base [1,2,5,19,20,24,25]. Bondarenko described the LEUR tech-
nique in 10 pediatric patients with a transversally oriented tunnel [3].
In this author's experience, the transversal orientation in comparison
with anterolateral provides a longer length of tunnel for the dilatated
ureter improving the antireflux mechanism.
Regarding tunnel length traditionally, in ureteral reimplantation, the
need to achieve a certain length of submucosal tunnel arises from the
demonstration by Paquin that a nonrefluxing ureter has to have a length
of submucosal course of at least five times the diameter of the ureter.
Most of the published articles recommend about four times the size of
the ureter or a ratio 5:1 [1,17,18,20,26]. In practical terms this means a
3–4 cm tunnel suffices in most cases. Bondarenko described a tunnel
length dependent on the patients’ age: from 5 cm in younger to 7–8 cm
in older children [3]. However, more recent studies suggest that other fac-
tors, such as ureteric orifice configuration, have even a greater impact on
the antireflux mechanism than only the tunnel length [23,27–29]. In this
novel simplified technique, as mentioned previously, the length of the
tunnel does not really matter because the antireflux mechanism does
not entirely depend on that and 2–3 cm of detrusoromyotomy is suffi-
cient. The detrusor must only be approximated over the anastomosis
with two to three stiches. This in turn, limits the dissection downwards
to the ureterovesical hiatus where the pelvis plexus is located.
When the authors first described their experience in LEUR for pri-
mary OM with extracorporeal ureteral tapering, the vesicoureteral
anastomosis was carried out by two continuous 6/0 PDS sutures,
which are technically demanding [1]. Similarly, other authors described
vesicoureteral anastomosis with interrupted fashion using 4/0–5/0
polyglactin [5,20,24]. In order to make the procedure technically easier,
decrease surgical time and, most-importantly, reduce manipulation of
the ureter, we used a modification of the Shanfield ureteral reimplanta-
tion technique [21]. A similar adaptation, using a single ‘U-stitch’, has
been recently described for the laparoscopic Mitrofanoff procedure
[30]. We perform a similar, but modified adaptation of this technique
by introducing 1.5–2 cm of the distal ureter into the bladder, without
spatulation. In this way, there is no full mucosal apposition and the ure-
ter is only fixed to the bladder mucosa by four stitches. This modifica-
tion makes the procedure simpler and more reproducible, and at the
same time, reduces the risk of postoperative leakage.
Please cite this article as: R. Gander, M. Asensio, G.F. Royo, et al., Laparoscopic Extravesical Ureteral Reimplantation for Correction of Primary and
Secondary Megaureters: Prelimi..., Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.05.028
5
Tapering of the ureter has been described to satisfy the 5:1 rule, be-
cause in the absence of tapering a very dilated ureter would need a long
submucosal tunnel [5]. In LEUR for OM, ureteral tailoring has been de-
scribed intra and extracorporeally [1,3–5,24]. When the antireflux
mechanism no longer depends on this 5:1 ratio, as in our technique,
there is no need for ureteral tapering. This obviates the need for JJ
stenting, shortens operative time and decreases the risk of postopera-
tive urinary leak and ureteral ischemia.
This simplified technique should allow one-stage laparoscopic reim-
plantation of OM even in young children (avoiding intermediate proce-
dures such as ureterostomies and double J stenting) owing to shorter
operative times and shorter submucosal tunnels. Additionally, it avoids
extensive dissection of the bladder and reduces the risk of pelvic plexus
injuries and subsequent transitory urinary retention.
In terms of complications, the Shanfield ureteral reimplantation
technique has been related to increased risk of ureteral complications
when compared with the Lich–Gregoir technique, but manly in the
field of KT. Jeffrey et al. evaluated 721 consecutive KTs and reported
an increased risk of hematuria and stone formation, which was signifi-
cantly higher than in the Lich–Gregoir group [22]. Alberts et al. per-
formed a systematic review and meta-analysis comparing three
different ureterovesical anastomotic techniques for KT (Shanfield,
Lich–Gregoir and Politano–Leadbetter), and observed a higher inci-
dence of hematuria in the Shanfield group, while ureteral strictures
and VUR were similar to other techniques [31]. This higher risk of hema-
turia seems to be related to the exposure of the ureteral stump to urine
and can be minimized with meticulous stump hemostasis. In our expe-
rience, the Shanfield technique was related to higher incidence of he-
maturia when we used it in KT, while in this laparoscopic technique
we did observe only mild hematuria with a tendency to spontaneous
resolution within the first 48–72 h after surgery in all cases.
We acknowledge the limitations of this study owing to the small
number of patients and limited follow-up. This novel simplified tech-
nique may offer comparable results to open surgery but needs to be
evaluated in further prospective and high-quality studies.
5. Conclusions
We believe that LEUR by this new technique may be a feasible treat-
ment of megaureters, even in very young children, associated with good
short-term results. Most importantly, this technique is simpler and
more easily reproducible than conventional LEUR avoiding the need
for excessive manipulation of both the ureter and the bladder. While
success rates are similar to open surgery, it offers the advantages of min-
imally invasive surgery such as superior cosmetic results and significant
convalescence advantages. However, larger series with longer follow-
up are needed to support these results.
Funding
This research did not receive any specific grant from funding agen-
cies in the public, commercial, or not-for-profit sectors.
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