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Ureterocystoplasty

Ureterocystoplasty is a form of augmentation cystoplasty that uses a detubularized, reconfigured dilated ureter (megaureter) to enlarge the bladder. First described by Bellinger in 1993, its principal advantage is that the augmenting tissue is native urothelium with muscular backing, eliminating the metabolic disturbances, mucus production, and malignancy risk associated with enterocystoplasty.[1][2] It is considered the augmentation of choice when a suitable megaureter is available.[3][4]

Indications​

Ureterocystoplasty requires the presence of a dilated ureter (megaureter), which limits its applicability:[1][2][3][5]

  • Neurogenic bladder with associated megaureter and VUR.
  • Posterior urethral valves with VURD syndrome (vesicoureteral reflux dysplasia) and a nonfunctioning kidney with ipsilateral megaureter.
  • Bladder exstrophy / cloacal exstrophy with dilated ureters.
  • Massive VUR (grade IV–V) with a dilated, tortuous ureter.
  • Ureterocele with associated megaureter.
  • Patients with chronic renal failure in whom the metabolic consequences of enterocystoplasty would be poorly tolerated.[6]

Patient Selection — Predictors of Success​

Husmann's multicenter study (n=64) identified the key predictors:[4]

  • Ureteral diameter > 1.5 cm in patients without reflux: none of 6 patients with diameter > 1.5 cm required re-augmentation (median capacity ↑ 6-fold, compliance ↑ 50-fold). All 3 patients with diameter < 1.5 cm required re-augmentation.
  • Compliance > 20 mL/cm H₂O in patients with reflux: 6 patients with mild noncompliance had successful outcomes.
  • Severely noncompliant augmenting system (< 20 mL/cm H₂O) had high re-augmentation rates.

The procedure is best reserved for patients with ureteral diameter > 1.5 cm, or with reflux and mild noncompliance (> 20 mL/cm H₂O) on preoperative urodynamics of the entire system.[4]

Surgical Technique​

Scenario 1: Nonfunctioning ipsilateral kidney (classic)[1][2][7]​

  1. Ipsilateral nephrectomy.
  2. Mobilize the entire dilated ureter (and often the renal pelvis), preserving its blood supply.
  3. Detubularize the ureter longitudinally along its antimesenteric border.
  4. Fold opened ureter into a U-shape or patch.
  5. Bivalve the bladder (sagittal cystotomy).
  6. Suture the reconfigured patch to the opened bladder as a cup-patch augmentation.

Scenario 2: Functioning ipsilateral kidney (renal preservation)[8][9]​

A functioning ipsilateral kidney is not a contraindication (Gosalbez–Kim).

  1. Transureteroureterostomy (TUU): ipsilateral ureter divided; proximal stump anastomosed to the contralateral ureter to maintain renal drainage.
  2. The distal dilated ureter is then used for augmentation.
  3. With partial ureteral duplication, ipsilateral upper-to-lower ureteropyelostomy can be added to maximize available ureter.[8]
  4. Pressure-specific bladder capacity ↑ 350% (142 → 500 mL) in this series.[8]

The procedure can be performed entirely extraperitoneally (Dewan and Condron) — renal preservation, TUU, and ureterocystoplasty without entering the peritoneal cavity.[9]

Scenario 3: Bilateral megaureters​

When both ureters are dilated:[10][11][12][13][14]

  • Both ureters used for augmentation (with bilateral nephrectomy if both kidneys nonfunctional, or TUU if functional).
  • Distal two-thirds of both ureters for augmentation, proximal ureters anastomosed to a tubularized ileal segment ("common ileal ureter") reimplanted in the bladder.[13]
  • One ureter for augmentation, the other for a Mitrofanoff channel (teapot technique).[14]

Perovic advocated that ureterocystoplasty "could be performed more frequently" by dividing the megaureter — distal portion for augmentation, proximal for reimplantation.[12]

Technical Modifications​

  • Teapot ureterocystoplasty (Kajbafzadeh): for bilateral megaureters with neurogenic bladder. Larger ureter for augmentation, keeping its distal 2 cm tubularized (the "teapot spout"); opposite ureter for a ureteral Mitrofanoff channel. At median 121 mo (10 yr), all 13 patients dry, no repeat augmentation, no bladder calculi; median postoperative capacity 430 mL (vs 210 mL pre-op, p=0.001).[14]
  • Common ileal ureter (Frimberger): distal two-thirds of both megaureters for augmentation; proximal stumps anastomosed to a tubularized, tapered ileal segment reimplanted in the bladder. In 6 patients, capacity ↑ up to 12-fold; mean compliance 58 mL/cm H₂O; no re-augmentation.[13]
  • Laparoscopic ureterocystoplasty (Landa Juárez): fully laparoscopic in 4 pediatric patients with myelomeningocele, combined with a Mitrofanoff using the proximal ureter. At 2–4 yr, all patients ≥ 75% of expected age-bladder capacity; compliance 15–20 mL/cm H₂O; bladder leak-point pressure < 40 cm H₂O.[15]

Outcomes​

SeriesnTissue usedFollow-upCapacityContinenceRe-augmentation
Churchill 1993[2]16Complete ureter ± pelvis22 moGood capacity, low pressure10/16 fully continent0%
Landau 1994[25]8 (vs 8 ileum)MegaureterLong-term417 mL (vs 381 mL ileum, p>0.05)Comparable12.5%
Zubieta 1999[10]32Variable (1 or 2 ureters, partial)16 mo375% (complete) / 230% (partial)92–100% improved0%
Pascual 2001[6]22Single distal ureter22 mo177%19/22 (86%) dry1/22 (4.5%)
Husmann 2004[4]64VariableVariableSelection-dependentVariable0–92% (selection-dependent)
Johal 2008[26]17Complete or partial4.5 yr125 → 292 mL13/17 adequate4/17 (24%)
Kajbafzadeh (teapot)[14]13Bilateral megaureters121 mo210 → 430 mL100%0%
Kilciler 2000[11]7Both ureters (functional kidneys)30 mo279 mL mean100%0%
Tekgül 2000[3]6Variable—263%100%0%

The landmark comparative study by Landau demonstrated equivalent urodynamic outcomes to ileocystoplasty — mean capacity 417 mL vs 381 mL (p>0.05); pressure-specific bladder volume 413 vs 380 mL (p>0.05) — without enterocystoplasty complications.[25]

Ureteral tissue quantity and outcomes (Zubieta)[10]​

  • Two ureters or one complete ureter: median capacity ↑ 375%; all patients had clinical improvement, decreased hydronephrosis, and resolution of reflux.
  • Distal ureteral segment only (with TUU): median capacity ↑ 230%; clinical improvement in 92.3%.
  • No significant difference between 1 vs 2 ureters — a single complete ureter provides sufficient tissue.
  • Even partial ureteral segments are a "safe alternative" that avoids enterocystoplasty in most patients.

Advantages Over Enterocystoplasty​

FeatureUreterocystoplastyEnterocystoplasty
Mucus productionNone (urothelial lining)Significant
Metabolic acidosisNoneHyperchloremic acidosis common
Malignancy riskNone (no entero-vesical junction)1.5–5.5% (latency ~20 yr)
Bowel complications (SBO, diarrhea)None4.5–8.5%
Bladder stonesVery low (0% in teapot series)5–21%
Vitamin B₁₂ / bile salt issuesNoneRisk with ileal/ileocecal segments
Surgical complexitySimpler; can be extraperitonealMajor intraperitoneal surgery
ApplicabilityLimited to patients with megaureterUniversal

Complications​

  • Failure requiring re-augmentation — most important complication. Rates 0–92%, depending critically on patient selection. Highest with short distal ureteral segments (5–8 cm) or severe noncompliance (< 20 mL/cm H₂O) of the augmenting system.[4]
  • Contralateral ureterovesical obstruction — 2/16 (12.5%) in Churchill series.[2]
  • Transient urine extravasation — 2/16 (12.5%); resolved spontaneously.[2]
  • Spontaneous perforation of the ureteral patch — rare; 1/22 patients (Pascual) required colocystoplasty.[6]
  • Persistent VUR — uncommon; 1/22 (Pascual), 3/16 (Perovic, without clinical symptoms).[6][12]
  • TUU-related complications — anastomotic stricture and contralateral ureteral obstruction. Suprapubic tube typically left for 2 weeks; Double-J stent for 1 mo.[10]

Special Considerations​

  • Pediatric population: predominantly performed in children with neurogenic bladder, PUV, or exstrophy. Avoids the lifelong metabolic and malignancy surveillance burden of enterocystoplasty.[1][3][5][26][27]
  • Renal insufficiency: especially valuable when chronic renal failure makes enterocystoplasty acidosis poorly tolerated. 5/22 patients in Pascual had CRF; all had successful outcomes.[6]
  • Growth of the augmented bladder: unlike enterocystoplasty (where bowel does not grow proportionally with the child), the urothelial-lined ureteral patch may have better growth potential, though long-term data are limited.
  • Combination with Mitrofanoff: with bilateral megaureters, one ureter for augmentation and the contralateral for a Mitrofanoff catheterizable channel (teapot technique or laparoscopic approach).[14][15]

Long-Term Follow-Up​

Surveillance is substantially less burdensome than after enterocystoplasty:[6][26]

  • Renal ultrasound for hydronephrosis and upper-tract status.
  • Urodynamic studies to confirm durable improvement in capacity and compliance.
  • VCUG to assess for VUR.
  • Renal function monitoring (serum creatinine).
  • No need for metabolic panels (no acid-base disturbance), B₁₂ monitoring, or cystoscopic malignancy surveillance.
  • CIC compliance — most patients require CIC, though some neurologically normal patients can void spontaneously.[3]

Summary​

Ureterocystoplasty is the ideal augmentation technique when a suitable megaureter is available, offering equivalent urodynamic outcomes to ileocystoplasty without the metabolic, mucosal, and malignancy complications of enterocystoplasty.[25] Its success depends critically on patient selection — adequate ureteral diameter (> 1.5 cm) and compliance (> 20 mL/cm H₂O) of the augmenting system.[4] The primary limitation is its restricted applicability to patients with dilated ureters, a minority of augmentation candidates.[5]

References​

1. Bellinger MF. "Ureterocystoplasty: A Unique Method for Vesical Augmentation in Children." The Journal of Urology. 1993;149(4):811-3. doi:10.1016/s0022-5347(17)36215-8

2. Churchill BM, Aliabadi H, Landau EH, et al. "Ureteral Bladder Augmentation." The Journal of Urology. 1993;150(2 Pt 2):716-20. doi:10.1016/s0022-5347(17)35596-9

3. Tekgül S, Oge O, Bal K, Erkan I, Bakkaloğlu M. "Ureterocystoplasty: An Alternative Reconstructive Procedure to Enterocystoplasty in Suitable Cases." Journal of Pediatric Surgery. 2000;35(4):577-9. doi:10.1053/jpsu.2000.0350577

4. Husmann DA, Snodgrass WT, Koyle MA, et al. "Ureterocystoplasty: Indications for a Successful Augmentation." The Journal of Urology. 2004;171(1):376-80. doi:10.1097/01.ju.0000100800.69333.4d

5. Diamond DA, Chan IHY, Holland AJA, et al. "Advances in Paediatric Urology." Lancet. 2017;390(10099):1061-1071. doi:10.1016/S0140-6736(17)32282-1

6. Pascual LA, Sentagne LM, Vega-Perugorría JM, et al. "Single Distal Ureter for Ureterocystoplasty: A Safe First Choice Tissue for Bladder Augmentation." The Journal of Urology. 2001;165(6 Pt 2):2256-8. doi:10.1016/S0022-5347(05)66178-2

7. Wolf JS, Turzan CW. "Augmentation Ureterocystoplasty." The Journal of Urology. 1993;149(5):1095-8. doi:10.1016/s0022-5347(17)36306-1

8. Gosalbez R, Kim CO. "Ureterocystoplasty With Preservation of Ipsilateral Renal Function." Journal of Pediatric Surgery. 1996;31(7):970-5. doi:10.1016/s0022-3468(96)90425-x

9. Dewan PA, Condron SK. "Extraperitoneal Ureterocystoplasty With Transureteroureterostomy." Urology. 1999;53(3):634-6. doi:10.1016/s0090-4295(98)00363-x

10. Zubieta R, de Badiola F, Escala JM, et al. "Clinical and Urodynamic Evaluation After Ureterocystoplasty With Different Amounts of Tissue." The Journal of Urology. 1999;162(3 Pt 2):1129-32. doi:10.1016/S0022-5347(01)68095-9

11. Kilciler M, Tan O, Tahmaz L, Dayanç M, Harmankaya C. "Ureterocystoplasty in Bilaterally Functional Kidneys." European Urology. 2000;38(6):742-7. doi:10.1159/000020372

12. Perovic SV, Vukadinovic VM, Djordjevic ML. "Augmentation Ureterocystoplasty Could Be Performed More Frequently." The Journal of Urology. 2000;164(3 Pt 2):924-7. doi:10.1097/00005392-200009020-00003

13. Frimberger D, Klein J, Kropp BP. "The Common Ileal Ureter: A New Technique for Compliant Ureterocystoplasty." The Journal of Urology. 2007;178(4 Pt 2):1819-22. doi:10.1016/j.juro.2007.03.158

14. Kajbafzadeh AM, Farrokhi-Khajeh-Pasha Y, Ostovaneh MR, Nezami BG, Hojjat A. "Teapot Ureterocystoplasty and Ureteral Mitrofanoff Channel for Bilateral Megaureters: Technical Points and Surgical Results of Neurogenic Bladder." The Journal of Urology. 2010;183(3):1168-74. doi:10.1016/j.juro.2009.11.052

15. Landa Juárez S, Fernández AM, Castro NR, De La Cruz Yañez H, Hernández CG. "Laparoscopic Ureterocystoplasty With Mitrofanoff System." Journal of Laparoendoscopic & Advanced Surgical Techniques. 2014;24(6):422-7. doi:10.1089/lap.2013.0290

25. Landau EH, Jayanthi VR, Khoury AE, et al. "Bladder Augmentation: Ureterocystoplasty Versus Ileocystoplasty." The Journal of Urology. 1994;152(2 Pt 2):716-9. doi:10.1016/s0022-5347(17)32689-7

26. Johal NS, Hamid R, Aslam Z, et al. "Ureterocystoplasty: Long-Term Functional Results." The Journal of Urology. 2008;179(6):2373-5. doi:10.1016/j.juro.2008.01.170

27. Gilbert SM, Hensle TW. "Metabolic Consequences and Long-Term Complications of Enterocystoplasty in Children: A Review." The Journal of Urology. 2005;173(4):1080-6. doi:10.1097/01.ju.0000155248.57049.4e