Duplication of the ureter, an anomaly where an individual is born with two ureters on one side, often presents clinically during childhood due to recurrent urinary tract infections or hydronephrosis. However, a significant number of cases remain asymptomatic and are discovered incidentally in adulthood, usually during investigations for unrelated abdominal issues or while evaluating flank pain. While many duplicated systems function without issue, others can lead to complications like vesicoureteral reflux (VUR), obstruction, or upper urinary tract deterioration. Open surgical correction remains a mainstay for managing symptomatic duplication, particularly in adults where endoscopic approaches may be limited by anatomical factors and the complexity of the underlying problem. This article will explore the intricacies of open correction of duplicated ureters in adult patients, focusing on assessment, surgical techniques, and expected outcomes.
The decision to intervene surgically isn’t always straightforward. Adult patients often have a different clinical presentation than children, with less likelihood of active infections and more emphasis on preserving renal function. A thorough understanding of the duplicated system – including the relative contribution of each ureter to overall kidney drainage – is paramount before proceeding with any intervention. This requires detailed imaging studies and ideally, functional assessment like diuresis scans or MAG3 renal scans. The goal isn’t just to ‘fix’ the duplication but to optimize urinary tract function while minimizing the risk of iatrogenic damage. Surgical planning must carefully consider which ureter is more dominant, whether reflux exists in either system, and the presence of any associated abnormalities like stenosis or strictures. Ultimately, successful management requires a tailored approach based on individual patient needs and anatomical characteristics.
Preoperative Evaluation & Imaging
A comprehensive preoperative evaluation is critical for determining the appropriate surgical strategy. This begins with a detailed history focusing on symptoms such as flank pain, recurrent UTIs, hematuria, or urinary leakage. Physical examination should assess for flank tenderness and signs of abdominal masses. However, the cornerstone of diagnosis remains imaging. Initial evaluation typically starts with ultrasound, which can identify hydronephrosis and suggest ureteral duplication. But more advanced imaging is necessary to fully characterize the system.
Computed tomography (CT) urogram provides detailed anatomical information about both ureters, their relationship to surrounding structures, and any associated abnormalities like obstruction or stones. It allows surgeons to visualize the point of entry into the bladder and assess for VUR.
Magnetic resonance urography (MRU) offers similar anatomical detail without radiation exposure, making it a preferred option in some cases, especially for patients requiring repeated imaging.
Diuresis renal scans (Lasix renal scan) or MAG3 renal scans are essential for assessing the functional contribution of each ureter to overall kidney drainage. This helps determine which ureter is dominant and guides surgical decision-making regarding which ureter to reimplant or excise.
Beyond imaging, baseline laboratory tests, including complete blood count, creatinine, electrolytes, and a urine analysis, provide information about renal function and potential infection. Cystoscopy may also be performed to directly visualize the ureteral orifices within the bladder and assess for reflux. Accurate assessment of both anatomy and function is key to optimizing surgical outcomes.
Surgical Techniques: Upper Pole Ureterectomy & Reimplantation
The most common approach for correcting duplicated ureters in adults involves upper pole ureterectomy with reimplantation of the dominant lower pole ureter. This technique is particularly suitable when the upper pole system is non-functional or significantly obstructed and contributes little to overall kidney drainage. The procedure typically involves:
Open abdominal incision allowing access to the kidneys and ureters.
Dissection of the duplicated ureters, carefully identifying each system.
Ligation and removal of the upper pole ureter proximal to the renal pelvis. This is usually performed using endo-GIA stapler or surgical clips followed by suture ligation.
Reimplantation of the lower pole ureter into the bladder using a technique like the Lichner or Leadbetter procedure, ensuring an anti-reflux mechanism.
Careful attention must be paid to avoid injury to the renal vasculature and collecting system during dissection and ureterectomy. Reimplantation is crucial for preventing VUR and restoring normal urinary drainage. The choice of reimplant technique depends on surgeon preference and anatomical considerations.
In cases where both duplicated ureters are functional, a Y-plasty may be considered. This involves creating a single, larger channel from the two ureters to drain into the bladder. While technically challenging, it aims to preserve renal function in both upper and lower poles. The procedure requires meticulous dissection and precise suturing to create a competent anti-reflux valve.
Alternatively, if one ureter is significantly narrowed or obstructed, ureteral reconstruction might be necessary before reimplantation. This could involve techniques like ureteral splinting, buccal mucosa graft augmentation, or utilizing a Boari flap to increase the diameter of the compromised ureter. The goal is to create a functional, non-obstructed urinary tract with minimal risk of reflux.
Postoperative Management & Expected Outcomes
Postoperative management typically involves Foley catheter drainage for 7-14 days to allow healing and assess for leaks or obstruction. Patients are monitored closely for signs of infection or complications like hematuria. Renal function is assessed postoperatively using blood tests and imaging studies. Long-term follow-up is essential to evaluate the effectiveness of the correction, monitor for recurrence of reflux, and ensure ongoing renal health.
Expected outcomes vary depending on the preoperative status of the kidney and the surgical technique employed. Generally, patients experience resolution of symptoms like flank pain and recurrent UTIs. Renal function should be preserved or improved in most cases, although some degree of functional loss may occur if the upper pole system was non-functional preoperatively. Complications can include:
Ureteral stricture
Reflux recurrence
Infection
Bleeding
Injury to surrounding structures
Open correction of duplicated ureters in adults is a complex but effective procedure when performed by experienced surgeons. A thorough preoperative evaluation, meticulous surgical technique, and diligent postoperative follow-up are crucial for achieving optimal outcomes and improving the patient’s quality of life. It’s important to remember that each case requires individualized assessment and management based on specific anatomical and functional characteristics.
