Skip to main content

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, avoiding bowel-segment mucus production and urine–intestinal electrolyte absorption when no bowel is incorporated into the urinary tract. It does not eliminate all metabolic, stone or malignancy risks of the underlying disease.[1][2] It is an option for selected patients with enough suitable ureteral tissue; adequacy of the patch, renal preservation and the likely need for later augmentation must be considered.[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) reported associations with success in small subgroups:[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.

These historical thresholds describe selected subgroups, not validated universal eligibility or safe-pressure rules. Distal-segment results differ between series, and the Husmann abstract contains inconsistent subgroup totals; its quoted 92% failure rate should not be used as a precise general estimate. Assess available tissue and the entire refluxing system on preoperative imaging and urodynamics.[4]

Surgical Technique​

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

  1. Confirm the ipsilateral renal unit is nonfunctioning and that nephrectomy is appropriate; do not sacrifice a functioning kidney merely to obtain augmentation tissue.
  2. Mobilize the entire dilated ureter (and often the renal pelvis), preserving its blood supply.
  3. Open the ureter longitudinally away from its preserved vascular attachments, avoiding injury to the adventitial blood supply.
  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. In the five-patient series, mean capacity at 30 cm H₂O increased from 142 to 500 mL. The abstract labels this a 350% increase, but those values represent about a 252% increase; retain the measured values rather than the erroneous percentage.[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]

  • Bilateral ureteral tissue: the operative plan must preserve a drainage route from every functioning renal unit. Distal patches may be combined with proximal ureteral reimplantation or another reconstruction; TUU alone cannot restore drainage if both receiving distal ureters have been fully opened for augmentation. Bilateral nephrectomy belongs only to independently indicated management of nonfunctioning kidneys.
  • 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 six patients at median 45.3 months, capacity increased up to 12-fold and mean compliance reached 58 mL/cm H₂O; none required repeat augmentation, but one required endoscopic incision of the reimplantation. This does use bowel in the urinary tract, so the bowel-free metabolic advantages do not fully apply.[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-upCapacityReported clinical outcomeRe-augmentation
Churchill 1993[2]16Complete ureter ± pelvis22 moGood capacity, low pressure10/16 fully continent0%
Landau 1994[16]8 (vs 8 ileum)MegaureterLong-term417 mL (vs 381 mL ileum, p>0.05)7/8 normal postoperative urodynamicsNot established by the abstract
Zubieta 1999[10]32Variable (1 or 2 ureters, partial)16 mo375% (complete) / 230% (partial)92–100% clinical improvement, not a dry rate0%
Pascual 2001[6]22Single distal ureter22 mo177%19/22 (86%) dry1/22 (4.5%)
Husmann 2004[4]64VariableVariableSelection-dependentVariableStrongly selection-dependent; inconsistent abstract totals
Johal 2008[17]17Complete or partial4.5 yr125 → 292 mL13/17 avoided further augmentation, not a dry rate4/17 (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%

Landau compared eight ureterocystoplasty patients with eight age- and diagnosis-matched ileocystoplasty controls. Mean capacity was 417 versus 381 mL and pressure-specific volume 413 versus 380 mL (both p>0.05). A nonsignificant difference in this small nonrandomized comparison does not establish equivalence or long-term freedom from complications.[16]

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 one versus two ureters was detected in this small study; this does not prove that any single ureter provides sufficient tissue.
  • Selected partial segments performed well in this series, but other cohorts had substantial failure; tissue length, width and quality matter.

Advantages Over Enterocystoplasty​

IssueWhat can be said
Mucus and electrolyte absorptionA urothelial patch avoids bowel-specific mucus and urine–intestinal absorption if no bowel is used elsewhere in the reconstruction.
Metabolic or B₁₂ monitoringBowel-specific supplementation may not be needed for a purely ureteral patch, but kidney disease and other clinical indications still require laboratory monitoring.
Malignancy and stonesNo enterovesical junction is created, but zero lifetime cancer or stone risk has not been established.
Bowel morbidityAvoids bowel harvest in a bowel-free operation; it does not establish zero risk of ileus or other abdominal complications.
Complexity and applicabilityTissue availability and the need for TUU, reimplantation or renal surgery can make reconstruction complex. Neither approach is universally suitable.

Complications​

  • Failure requiring re-augmentation — most important complication. Rates vary substantially with selection and available tissue; avoid treating the inconsistent 92% abstract subgroup estimate as a population risk. 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 bowel-specific consequences when the reconstruction is entirely bowel-free, but does not remove the need for lifelong monitoring of the original bladder and renal disorder.[1][3][5][17][18]
  • Renal insufficiency: especially valuable when chronic renal failure makes enterocystoplasty acidosis poorly tolerated. Five of 22 patients in Pascual had chronic renal failure, but the abstract does not separately establish success for every member of that subgroup.[6]
  • Growth and durability: monitor bladder capacity and pressures as the child grows; superior growth compared with bowel augmentation has not been established.
  • 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 remains necessary and should reflect the underlying bladder disorder, renal function and upper-tract reconstruction:[6][17]

  • 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).
  • A purely ureteral patch does not itself create bowel-related B₁₂ malabsorption or urinary electrolyte exchange. Obtain metabolic tests as indicated by kidney disease or other clinical factors. A common ileal ureter or other bowel component requires bowel-reconstruction follow-up. Investigate hematuria or other new symptoms; do not assume absence of malignancy risk.
  • CIC compliance — most patients require CIC, though some neurologically normal patients can void spontaneously.[3]

Summary​

Ureterocystoplasty can improve storage using native urothelium in a limited group with suitable megaureters. Small comparative and case-series evidence does not establish equivalence to ileocystoplasty or universal superiority. Counsel about renal drainage reconstruction, catheterization and possible later augmentation.[4][16][17]

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

16. 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

17. 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

18. 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