+ MODEL

Journal of Pediatric Urology (2015) xx, 1.e1e1.e6

Retrospective study to determine the

short-term outcomes of a modified
pneumovesical GlenneAnderson
procedure for treating primary
obstructing megaureter
Department of Urology,
Chongqing Children’s Hospital,
Chongqing Medical University, Xing Liu, Jun-Hong Liu, De-Ying Zhang, Yi Hua, Tao Lin,
Chongqing, China
Guang-Hui Wei, Da-Wei He
Correspondence to: D.-W. He,
Department of Urology, Summary Results
Children’s Hospital of The procedure was successfully performed in 62/63 patients.
Chongqing Medical University, The mean operating time was 105 min. Twelve months after
136 Zhongshan Er Road, Introduction surgery 90% of ureters were considered cured and 10% were
Yuzhong District, Chongqing, Primary obstructive ureter (POM) is an upper urinary tract considered improved. In patients who showed improvement
China malformation in children. Transvesicoscopic ureteral reim- ureters, the ureter diameter was significantly reduced from
plantation is increasingly being used as the first choice to preoperative measurements as early as 1 month post surgery.
[email protected] (D.-W. He) correct POM, replacing the open extravesical approach.
Although several procedures have been reported, there is Discussion
Keywords no universally accepted technique for endoscopic ureteral The GlenneAnderson technique advances the ureteral
Ureter; Laparoscopy; reimplantation. orifice distal to the trigone near the bladder neck and al-
Reimplantation lows relatively easy access to the upper urinary tract.
However, the submucosal tunnel produced is relatively
Received 13 August 2014 Objective short, and the surgery is not recommended for patients
Accepted 23 March 2015 To report on several modifications of the GlenneAnderson with a small trigone or megaureter because of anatomical
Available online xxx ureteral advancement technique to make it suitable for a considerations. This study made two major modifications
laparoscopic pneumovesical approach to treatment of POM. to the traditional GlenneAnderson procedure: (1) the
bladder wall was incised superiorolaterally to move the
hiatus proximally along the course of the ureter and the
Patients and methods detrusor muscle was sutured to the seromuscular layer of
From February 2006 to December 2013, 63 children with the ureter, and (2) a mucosal groove rather than tunnel
POM, 45 male and 18 female (median age 4.2 years; range 2 was used for advancement from the ureteral hiatus to the
monthse14 years), underwent modified transvesicoscopic bladder neck. This approach preserves conventional
ureteral implantation surgery. The technique was modified endourologic access to the upper tracts; however, the
by repositioning of the hiatus proximally to afford greater stabilizing distal stitch does leave the suture line in
“tunnel” length, and use of a trough rather than a tunnel, proximity to the mucosal suture line, a theoretical disad-
avoiding the challenges of more adherent mucosa in the vantage from the standpoint of ureterovesical fistula.
trigone. Ureter diameter was followed over a 12-month
period post surgery. Voiding cystourethrography (VCUG), Conclusions
intravenous urogram (IVU), or radionuclide imaging were These preliminary results indicate that this modified
conducted in patients who still had ureteral dilation at 6 transvesicoscopic ureteral implantation is an effective
months and 12 months after surgery. procedure with minimal morbidity.

Figure Transvesicoscopic ureteral reimplantation for an 11-month-old girl. After confirming the
locations of trocars (left), we began the operation with a 5-mm trocar as the midline camera port and
two 3-mm trocars as the working ports (right).

http://dx.doi.org/10.1016/j.jpurol.2015.03.020
1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
1.e2 X. Liu et al.

Introduction Materials and methods

Primary obstructive ureter (POM) is an upper urinary tract Patient enrollment and characteristics
malformation in children, and has the potential to cause long-
term kidney damage and pyelonephritis [1]. POM occurs in Sixty-three patients (45 male, 18 female) ranging in age
0.36 of 1000 to 1 of 1500 live births [1,2]. Treatment for POM is from 2 months to 14 years (median age 4.2 years) were
generally a “watchful-waiting” approach and/or antibiotic recruited at our hospital from February 2006 to December
prophylaxis to prevent recurrent UTIs. However, 21e23% of 2013. Preoperatively, patients were evaluated with at least
POM patients [1,2] will require surgical treatment for two urinary system ultrasounds, VCUG, and either an IVP or
breakthrough infections and worsening dilation of ureters. radionucleotide (DMSA) study. Indications for surgery
Ureteral reimplantation has a high success rate, over 90%, included recurrent urinary tract infections (9 cases),
for effective treatment of urinary reflux [3]. However, there deterioration of split renal function (46 cases), and signif-
is no universally accepted technique for endoscopic ureteral icant worsening dilation of ureters (24 cases).
reimplantation to treat POM and vesciouretal reflux (VUR). Informed consent and treatment options were discussed
Various surgical techniques have been reported, including with parents and, if possible, the patients. The patients
extravesical Lich-Gregoir technique [4], endoscopic trig- underwent the modified pneumovesical GlenneAnderson
onoplasty [5], Politano-Leadbetter technique [6], Glenn ureteral reimplantation to treat POM. Six cases were
eAnderson reimplantation, and the Cohen procedure. The bilateral and 57 were unilateral. The mean diameter of the
Cohen and GlenneAnderson reimplantation procedures are megaureter was 12 mm (range 8e22 mm). Patients with
the most widely accepted to correct POM or VUR [7e10]. In dilating vesicoureteral reflux were not included in this
the Cohen procedure, the ureter is rerouted so that it tunnels series.
across the trigone to exit the contralateral half of the
bladder. The Cohen procedure allows for ample bladder to be
used for the tunnel with very little in terms of anatomic lim- Surgical procedure
itations in how far the tunnel can be extended. However,
altering the normal anatomical alignment of the ureter makes The initial steps of this operation have been reported pre-
retrograde access to the upper urinary tract difficult [11,12]. viously by Yeung et al. [7]. Briefly, the patient was placed in
Furthermore, cross-trigonal dissection is more likely to the dorsal lithotomy position. A 5-mm trocar was used for
disturb the contralateral hemi-trigone and could result in a the midline camera port and two 5-mm trocars or 3-mm
higher rate of contralateral reflux [13]. In contrast, the trocars were used for the working ports. The operative
GlenneAnderson technique advances the ureteral orifice time was defined as the time from the start of cystoscopy to
distal to the trigone near the bladder neck and preserves the skin closure. The bladder was drained by inserting a ure-
normal course of the ureter. There is a reduced risk for ure- thral catheter, and CO2 insufflation to 10e12 mm Hg was
teral kinking or obstruction with this technique [8], it mini- started. The ureteral orifice was circumscribed using hook
mizes the impact on the hemi-trigone, and allows relatively electrocautery. The ureter was mobilized with a hook using
easy access to the upper urinary tract. In fact, minimally a blunt grasper to retract the ureteral end, taking care not
invasive treatments for upper tract nephrolithiasis are more to damage the main blood supply or the proximity of the vas
successful after the GlenneAnderson surgery than after the deferens in boys.
Cohen procedure [14]. An additional advantage is that the The following steps of the operation were our modifi-
muscular trigone would have to be considered an optimal cations. First, we made a 1e1.5 cm incision to the bladder
backing for the ureter in prevention of reflux. However, the wall proximal to the original ureteral orifice with a hook
submucosal tunnel produced is relatively short, and the sur- (Fig. 1B). Once adequate ureteral length was obtained, the
gery is not recommended for patients with a small trigone or mobilized ureter was drawn cephalad to expose the
megaureter because of anatomical considerations [15]. detrusor defect. The detrusor defect in the ureteral hiatus
Transvesicoscopic ureteral reimplantation is increasingly and the seromuscular layer of the ureter were closed with
replacing open extravesical approach in the field of pedi- one interrupted 5e0 absorbable suture (Fig. 1C). An addi-
atric urology. Its potential benefits include reduction in tional one to two interrupted sutures were used to close the
postoperative bladder spasms, decreased incisional blood detrusor defect entirely. Second, we developed a groove of
loss and pain, and improved cosmetics. Minimally invasive musculature from the hiatus to near the bladder neck using
procedures using a laparoscopic technique and CO2 insuf- hook electrocautery. The length of hiatus to distal aspect of
flation of the bladder (pneumovesicum) were introduced in the mucosal groove was equal to approximately five times
2005 [7]. Since then, there have been several advocates of the ureteral diameter (Fig. 1D,E). The terminal portion of
transvesical reimplantation for POM in children. Although the ureter was amputated to a suitable length where
this technology has several advantages, it has never ach- appropriate. The tip of the neoureteral opening was su-
ieved widespread acceptance. Because of the extremely tured to the end of the groove to better fix the ureter for
high level of skill required to perform the operation, lapa- tapering (seven patients) if needed. Excisional ureteral
roscopic techniques have been limited to a few select pe- tapering and ureterovesical anastomosis were performed
diatric surgeries and centers. Herein, we describe a using 5e0 absorbable interrupted sutures, taking care to
modified pneumovesical GlenneAnderson technique that reserve and not to damage the main longitudinal blood
achieves adequate submucosal length of the ureter to treat supply as much as possible. The mucosal layer was closed
POM in children. over the muscular groove with 5e0 absorbable running su-

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
Primary obstructing megaureter 1.e3

Figure 1 Surgical procedure steps. (A) Prior to mobilizing the ureter. a-indicates the proximal point of the hiatus; b-indicates the
original ureteral orifice; c-indicates the new ureteral opening at the trigone. (B) During the ureter mobilization. (C) The hiatus is
closed distal to the point of entry of the seromuscular layer of the ureter indicated by d. (D) The length of the groove (intramural
ureter) and (E) the width of the ureter are measured using a ureteral catheter. (F) Postoperative view.

tures (Fig. 1F). The use of 6Fr stenting ureteral catheters is ultrasonography was performed three times post-
optional for this surgery, but catheters were placed for all operatively after 1 month, 6 months, and 12 months. The
the patients that required ureteral tapering. A transure- diameter of the ureter was measured at the midureter level
thral Foley was inserted at the end of operation. before and after voiding to determine its dilation. VCUG,
The stenting catheter was removed 6 days post surgery DMSA scan, or IVU was conducted in patients who still had
and the patient was discharged the next day. The preop- ureteral dilation or no change at 6 months and 12 months
erative and postoperative anatomy is shown in Fig. 2. after surgery.

Follow-up procedure Statistical analysis

A successful result in all cases was defined as no detection Statistical analysis was conducted using SPSS13.0 (SPSS
of VUR or VUJ obstruction throughout the follow-up. Renal Inc., Chicago, IL, USA). Univariate analysis between mean

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
1.e4 X. Liu et al.

Figure 2 Sagittal views preoperation (left) and postoperation (right) of the vesicoureteral junction obstruction. The green lines
in left figure indicate the range of incisions. a, b, c, and d indicate the same points as in Fig. 1.

values was performed using a two-tailed t test for normally surgery was monitored over a 12-month period. The ma-
distributed data; p < 0.05 was considered statistically jority of the enrolled patients participated in follow-up
significant. procedures, although participation decreased over time
from 58 (93%) 1 month post surgery to 49 (79%) at 12 months
post surgery (Table 2). The surgical outcomes were quali-
Ethical approval
tatively described as “cured” Z no ureter found or diam-
eter  5 mm tested by ultrasonography;
Ethical approval was not required for this work. “improved” Z reduced dilation from preoperative mea-
sures but still present; “aggravated” Z increased dilation;
Results or “no change.” At 1 month post surgery, 38 (59%) ureters
were considered cured and 26 (41%) showed improvement
(Table 2). The percentage of ureters that were considered
The mean operating time for the total cohort was 105 min
cured increased at 6 months post surgery (44; 78%) and 12
(range 70e195 min). Patients who required unilateral sur-
months post surgery (48; 90%). There was a simultaneous
gery had a mean operating time of 92 min (range
decrease in the percentage of patients considered
70e170 min), bilateral operations required a mean of
175 min (range 110e195 min). To evaluate the learning
curve for the operating surgeon, the operative time was
compared between the first 15 unilateral patients and the
following 41 unilateral patients. One patient was converted Table 1 Demographic and intraoperative data.
to an open surgery because of displacement of the port, Age (median) 4.2 years
which resulted in gas leakage into the extravesical space. (range 2 monthse14 years)
This patient was excluded from the operative time analysis. Gender 18 female, 45 male
The surgeon required significantly longer to complete the Operative time (mins)
procedure in the first 15 unilateral patients Unilat ureter Mean 92 (range 70e170)
(113.2  38.7 min) than the following 41 unilateral patients Bilat ureters Mean 175 (range 110e195),
(80.6  19.2 min; p < 0.01, two-tailed t test) (Table 1). completed simultaneously
Blood loss was minimal in all cases. None of the patients First 15 unilat ureter Mean 113 (range 68e145)
developed postoperative wound infections. Of note, Last 41 unilat ureter Mean 80 (range 65e110)
bladder spasms were minimal, especially after removal of No. conversion to open 1/63 (1.6)
the urinary catheter. Pain medication, NSAIDs, was pre- surgery/total No. (%)
scribed as and when needed. No. laparoscopic 62/63 (98.4)
To evaluate the success of the modified laparoscopic success/total No. (%)
GlenneAnderson procedure, the clinical outcome of

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
Primary obstructing megaureter 1.e5

Table 2 Postoperative ureteral outcomes and comparison of ureteral diameter of improved ureters.
1 month 6 months 12 months
No. patients 58 52 49
No. cured ureters (%) 38 (59%) 44 (78%) 48 (90%)
No. improved ureters (%) 26 (41%) 12 (22%) 5 (10%)
Preoperative diameter (Mean  SD cm) 1.29  0.30 1.18  0.42 1.43  0.33
Postoperative diameter (Mean  SD cm) 0.65  0.04 0.72  0.18 0.79  0.15
p value (two-tailed t test) 0.030 0.015 0.005
No. no change/aggravated ureters 0 0 0
No. VCUG (reflux/tested) e 0/9 0/5
No. DMSA scan or IVU (obstruction/tested) e 0/8 0/4
Cured: No ureter was found or ureteral diameter  5 mm tested by ultrasonography.
Improved: Ureteral diameter was less than the postoperative value.
Aggravated: Increased ureteral diameter.

improved (Table 2). At no time post surgery did we detect musculature of the enlarged hiatus was then closed distal
aggravation to the ureter or no change. to the point of entry of the seromuscular layer of the ure-
We also quantified the ureter diameter over the 12- ter. As a result, the ureter was displaced to the proximal
month follow-up period in only those patients who showed portion of the hiatus and anchored on the bladder wall,
improvement, but were not considered cured. As early as 1 facilitating enough intramural ureteral length for the next
month post surgery, the diameter of the ureter was signif- step. Another important modification in the laparoscopic
icantly decreased from 1.29  0.30 cm prior to surgery to procedure is the creation of a groove, instead of a tunnel,
0.65  0.04 cm post surgery (p Z 0.030). Ureter diameter from the ureteral hiatus to the trigone. The muscle fibers of
was also significantly reduced 6 months and 12 months post the trigone are more compact than those of the detrusor,
surgery. In addition, where no postoperative VUR was and adhere firmly to the overlying mucosal layer [17]. His-
detected using VCUG, DMSA scans or IVU were also obtained tological differences make it more difficult to create the
and provided evidence of the resolution of the obstruction transverse submucosal tunnel in the trigone than in the
in these patients (Table 2). bladder, particularly under pneumovesical conditions.
In our series of operations, we achieved stable operative
skill level after 15 cases based on the time needed for
Discussion successful completion. Important skills are necessary for
adequate performance of this surgery. First, suturing the
The GlenneAnderson procedure to treat VUR was first re- tip of the neoureteral opening to the end of the groove
ported in 1967 by Glenn and Anderson [15]. In the original provides stability for the ureter during tapering. To girls, a
technique, the distal ureter was mobilized for 2e3 cm and blunt grasper may be introduced through urethra to clamp
the configuration of the ureterovesical hiatus was main- the ureteral end. Second, to avoid high tension across the
tained, which avoided enlargement of this hiatus. The groove, the bladder insufflation pressure should be down-
ureteral orifice was then advanced distally toward the regulated and the submucous layer may be slightly mobi-
trigone near the bladder neck to preserve the normal lized before closing the mucosal layer with running sutures.
course of the ureter. Glenn and Anderson realized that the However, the stabilizing distal stitch does leave the suture
length of the submucosal tunnel created was too short, line in proximity to the mucosal suture line, a theoretical
prohibiting the use of this procedure in infants and pa- disadvantage from the standpoint of ureterovesical fistula.
tients. In 1978, they reported their modified technique [8]. We did not find ureterovesical fistula in seven patients in
In the refined technique they deliberately enlarged the this study, but close attention should be paid to patients in
hiatus to permit the ureter to move further and diminish similar situations.
the necessary tunnel length distally on the trigone. They It has been suggested that pneumovesicoscopic trans-
believed that this modified technique also could be used to trigonal ureteric reimplantation is not appropriate for
correct ureterovesical junction obstructions. Retaining the children under 6 months of age [18]. However, in our series,
principles of adequate submucosal ureteral length and five infants between 2 and 3 months of age were surgically
preserving the normal course of the ureter, we have further treated, recovered uneventfully, and remain well. This
modified the GlenneAnderson procedure for trans- experience leads us to believe that skilled surgeons could
vesicoscopic conditions or for open surgery as well. use this modified procedure in younger patients with small
In our procedure, the primary modification was creating bladders. In our series, although the patients were all POM,
a ureteral hiatus that involved the proximal and distal sides the surgical process and operating time were similar when
of the ureteral orifice. A submucosal tunnel five times the treating VUR and POM.
length of the ureteral diameter is optimal for ureteral In the present study, we demonstrated that a modified
reimplantation [16]. To achieve this, the bladder wall was GlenneAnderson surgical technique resulted in favorable
incised proximal to the original ureteral orifice for outcomes for POM patients. Although there was no persis-
1e1.5 cm as the ureter was being mobilized. The bladder tent hydroureternephrosis observed, postoperative VUR or

Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020
 + MODEL
1.e6 X. Liu et al.

ureteral stricture might occur later, with implications for prospective, randomized, pain scale-oriented study in a pe-
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tion: a novel technique. J Endourol 2005;19:295e9.
[8] Glenn JF, Anderson EE. Technical considerations in distal
Conflict of interest tunnel ureteral reimplantation. J Urol 1978;119:194e8.
[9] Bi Y, Sun Y. Laparoscopic pneumovesical ureteral tapering and
reimplantation for megaureter. J Pediatr Surg 2012;47:
None. 2285e8.
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Funding Children’s Hospital of Philadelphia. J Urol 2006;176:2222e5.
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[12] Wallis MC, Brown DH, Jayanthi VR, Koff SA. A novel technique
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Please cite this article in press as: Liu X, et al., Retrospective study to determine the short-term outcomes of a modified pneumovesical
GlenneAnderson procedure for treating primary obstructing megaureter, Journal of Pediatric Urology (2015), http://dx.doi.org/10.1016/
j.jpurol.2015.03.020