Year : 2002 | Volume
: 19 | Issue : 1 | Page : 82--83
Recurrent vesicoureteric reflux due to ureterovesical fistula following ureteric reimplantation
TR Sai Prasad, DK Mitra, V Bhatnagar
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
Department of Pediatric Surgery, AIIMS, New Delhi - 110 029
|How to cite this article:|
Sai Prasad T R, Mitra D K, Bhatnagar V. Recurrent vesicoureteric reflux due to ureterovesical fistula following ureteric reimplantation.Indian J Urol 2002;19:82-83
|How to cite this URL:|
Sai Prasad T R, Mitra D K, Bhatnagar V. Recurrent vesicoureteric reflux due to ureterovesical fistula following ureteric reimplantation. Indian J Urol [serial online] 2002 [cited 2021 Jun 13 ];19:82-83
Available from: https://www.indianjurol.com/text.asp?2002/19/1/82/21995
An 18-year-old female presented to us in 1990 at the age of 8 years with exstrophy bladder. Primary turn-in with bladder neck repair was done, and the patient achieved acceptable continence following the procedure. 2 years later she presented with features of recurrent culture proven urinary tract infection (UTI). Voiding cystourethrogram (VCU) revealed bilateral gross vesicoureteric reflux (VUR). The patient underwent bilateral transtrigonal Cohen's ureteroneocystostomy with reduction-tapering ureteroplasty of the left ureter as it was dilated and tortuous. The surgery was successful as the VCU after 6 months following the procedure showed no reflux and the patient remained asymptomatic for 7 years when she presented with features suggestive of UTI. VCU revealed grade 4 reflux into the left ureter. The patient was explored and on opening the urinary bladder a 3 x 5 mm ureterovesical fistula (UVF) was recognized on the left ureter 2 cm proximal to the neo-meatus. The ureteral segment distal to the fistula and the neo-meatus were of normal caliber. The ureteric fistula was mobilized by a circumferential incision and the underlying ureter in the submucosal tunnel was isolated. The margins of the fistula were trimmed and closed with interrupted 5-0 vicryl sutures. The submucosal tunnel was reconstituted after placing the repaired ureter in the tunnel and closing the overlying mucosa with 5-0 vicryl continuous suture. The ureter was splinted with 5F infant feeding tube for 10 days. Following the procedure the patient was placed on cyclical prophylactic antibiotics. The VCU done 6 months after the procedure revealed no reflux and the chemoprophylaxis was stopped. The patient is presently asymptomatic following the corrective surgical procedure.
Complications following ureteroneocystostomy for VUR are rare and are usually attributed to technical failure. Various surgical procedures have been described to circumvent the associated complications, but some pitfalls in the form of stenosis of the ureteric orifice or recurrent reflux do exist. Recurrent VUR usually results because of inadequate submucosal tunnel length or retraction of the implanted ureter. VUR secondary to UVF is very rare. Several factors have been attributed for the occurrence of UVF, viz, pressure necrosis due to rigid, inappropriatesized ureteric splints which are left in situ for an inordinate time, acute angulation of the ureter at the bladder hiatus, too tight a bladder hiatus compressing the ureter, injudicious handling of tissues leading to ureteric ischemia, inadvertent placement of sutures while closing the mucosa over the ureter in the submucosal tunnel may transfix the ureter resulting in ischemia and necrosis of ureteric and bladder mucosa, breakdown of the suture line following reduction tapering ureteroplasty and ureteroneocystostomy.
Although Politano  suggested that most of the UVF result in patients who have undergone reduction ureteroplasty there are no ample case reports to support the same. Only few case reports are available in the literature describing this unusual complication. ,, In all these case reports the condition was treated by excision of the ureteric segment distal to the fistula and reimplantation of the ureter after achieving adequate length by intravesical or combined intravesical and extravesical mobilization of the ureter. The present report is the first case report of the association of this unusual complication following ureteroneocystostomy in an exstrophy patient and of the novel concept of simple intravesical closure of UVF. This procedure prevents unnecessary perivesical dissection and consequent neurogenic vesical dysfunction in some patients.
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