Surgical Management of Megaureter
The surgical management of megaureter should include ureteral reimplantation with or without tapering, with stent placement strongly recommended in all cases to reduce failures and strictures. 1
Initial Assessment and Indications for Surgery
Surgical intervention for megaureter is indicated in cases of:
- Recurrent urinary tract infections
- Deterioration of split renal function
- Significant obstruction
- Symptoms affecting quality of life 2
Surgical Techniques
1. Ureteral Reimplantation Options
For Proximal Megaureter (Above Iliac Vessels)
- Primary repair over a ureteral stent when possible
- Spatulated, tension-free anastomosis after debridement of non-viable tissue
- Mobilization of ureter while preserving maximal blood supply 1
For Distal Megaureter (Below Iliac Vessels)
- Ureteral reimplantation is preferred over ureteroureterostomy
- Options include:
- Intravesical approach (Cohen's trans-trigonal technique)
- Extravesical approach (Lich-Gregoir technique) 1
2. Ancillary Maneuvers for Tension-Free Reimplantation
- Bladder mobilization with psoas hitch
- Boari flap for additional length
- Avoid bowel interposition in acute settings 1
3. Ureteral Tapering Techniques
- Excisional tapering (Hendren technique) for severely dilated ureters
- Plication (Kalicinski technique) as an alternative to excisional tapering
- "Mini reimplantation" approach with excision of distal narrow segment without extensive tapering 3
4. Laparoscopic and Robotic Approaches
- Laparoscopic-assisted extracorporeal ureteral tapering repair (EUTR)
- Laparoscopic ureteral extravesical reimplantation (LUER) following Lich-Gregoir technique
- Robot-assisted laparoscopic ureteral reimplantation (RALUR) 2, 1
Approach Selection Based on Clinical Scenario
Primary Obstructive Megaureter:
Refluxing Megaureter:
- Intravesical approach may have higher success rates (86% vs 76% for extravesical) 4
Neonatal/Infant Management:
- Consider temporary refluxing ureteral reimplantation as internal diversion
- Definitive repair after 1 year of age 5
Stent Management
- Stent placement is strongly recommended in all ureteral repairs 1
- For complete ureteral transection with repair: maintain stent for 4-6 weeks 6
- For ureteral reimplantation: maintain stent for 2-4 weeks 6
- Remove stents as soon as healing is confirmed to minimize complications 6
Potential Complications and Management
- Vesicoureteral reflux: May occur in 15-20% of cases, especially with refluxing reimplantation techniques
- Persistent obstruction: May require revision surgery
- Urinary tract infections: Antibiotic prophylaxis may be needed
- Stent-related complications: Encrustation, migration, or infection 6
Follow-up Protocol
- Ultrasound at 3 months post-surgery to assess hydronephrosis
- Voiding cystourethrogram to rule out reflux if clinically indicated
- MAG3 renogram at 6-12 months to evaluate drainage and split renal function
- Long-term follow-up until after puberty for patients with complex repairs 1, 2
Pitfalls to Avoid
- Inadequate ureteral length for tunneling can lead to persistent reflux
- Excessive tapering can compromise ureteral blood supply
- Insufficient submucosal tunnel length increases risk of reflux
- Delayed stent removal can lead to encrustation and infection
- Failure to address voiding dysfunction can compromise surgical outcomes 6, 4
In summary, the surgical management of megaureter requires careful technique selection based on the location and severity of the megaureter. Stent placement is crucial for successful outcomes, and the approach (intravesical vs. extravesical) should be selected based on the specific clinical scenario, with special consideration for patients with voiding dysfunction.