Stenting in pneumovesicoscopic reimplantation: is it necessary?

Abstract

Aim

Ureteric stenting is widely used in open reimplantation, but not universal in pneumovesicoscopic reimplantation. Obstruction at the reimplant site due to early postoperative oedema is the main cause of concern. We present our experience in this regard.

Methods

Fifteen children with vesicoureteric reflux (VUR) who underwent pneumovesicoscopic Cohen’s reimplantation between 2019 and 2022 under a single surgeon were analyzed. Demographics, investigations, management details and outcome were collected retrospectively.

Results

Indications for reimplantation were recurrent urinary tract infection (UTI) with grade 3/4 reflux (9 unilateral and 5 bilateral). Few patients had associated conditions: one each of Fanconi’s anaemia, posterior urethral valves (PUV) with solitary functioning kidney, duplex system (common sheath reimplant done) and ipsilateral pelviureteric junction obstruction (PUJO) operated previously. Patients were not routinely stented. 3 patients were stented, based on single functioning kidney with renal impairment, immuno-compromised state or concern about the narrow neo-hiatus.

Among the 12 (22 ureters) non-stented children, 11 (20 ureters) had no complications. A 1.5-year-old male child with recurrent pyelonephritis, bilateral reflux (right—Grade 2, left—Grade 3), had anuria postoperatively for 20 h with uraemia. This resolved spontaneously (planned for percutaneous nephrostomy initially). Risk factors for reimplant obstruction in this child were recent pyelonephritis, persistent bladder mucosal inflammation at the time of surgery and lower grade reflux.

Conclusion

Pneumovesicoscopic reimplantation can be done safely without routine ureteric stenting. However, VUR with low-grade reflux without significant ureteric dilatation have the chances of ureteric obstruction, especially in the phase of residual bladder inflammation. Herein, stenting can be protective. We believe that presence of solitary kidney, renal impairment, re-do reimplant, tapering procedures and significant co-morbid conditions also warrant an elective stent insertion.