Dr. med. Dirk Manski

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Ureterocystoneostomy: Leadbetter, Cohen and Lich-Gregoir Technique

Transvesical Ureterocystoneostomy

Ureterocystoneostomy is the reimplantation of the ureter into the bladder and is used for treatment of vesicoureteral reflux (VUR). In the transvesical technique, the distal ureter is mobilized after opening the urinary bladder and reimplanted into a submucosal neotunnel (Steffens et al., 2006).

Schematic drawing of the Leadbetter antirefluxive ureteral reimplantation: One cause of reflux is insufficient length of the intramural ureter (left). After antirefluxive reimplantation, the ratio between ureter diameter and tunnel length should be at least 1:5 (right).
figure Schematic drawing of the Leadbetter antirefluxive ureteral reimplantation

Contraindications

Surgical Technique of Transvesical Ureterocystoneostomy

Preoperative Patient Preparation

Surgical Approach

A Pfannenstiel incision is sufficient to treat VUR in children. Fat is removed from the anterior wall of the bladder and disturbing blood vessels are coagulated. Place stay sutures and open the bladder vertically.  

Leadbetter-Politano Reimplantation:

Cohen Reimplantation:

After transvesical mobilization of the ureter, a submucosal tunnel is created in direction of the oppposite ureteral orifice. Pass the ureter including stent through the neotunnel to the new ostium and anchor like described above. The Cohen technique is considered easier as the ureter does not have to be repositioned. However, endoscopic interventions of the upper urinary tract (e.g., ureterorenoscopy) in the further course of life are difficult and a significant disadvantage.

Technical Modifications:

The Leadbetter and Cohen technique can be performed vesicoscopically (endoscopic robotic-assisted), series with small numbers have been published (Kruppa et al., 2023).

Postoperative Care after Transvesical Ureterocystoneostomy

General measures:

Early mobilization, thrombosis prophylaxis depending on age, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesia:

Analgesics with a combination of NSAIDs and opioids.

Drains and catheters:

Quickly remove the transurethral catheter depending on hematuria. Remove the pelvic drain if the daily drainage volume is below 50 ml. The ureteral splint can be removed after 5–7 days. Suprapubic catheter 8–10 days, a cystography is usually not necessary.

Complications of Transvesical Ureterocystoneostomy

Extravesical Lich-Gregoir Ureterocystoneostomy

Ureterocystoneostomy is the reimplantation of the ureter into the bladder and is used for treatment of vesicoureteral reflux (VUR). In the extravesical Lich-Gregoir technique, the intramural ureter is dissected extravesically from the dorsal side without opening the bladder (Riedmiller et al., 2008). Tunneling is achieved by incision and closure of the bladder wall above the ureter.

Contraindications

Surgical Technique of Extravesical Lich-Gregoir Ureteral Reimplantation

Preoperative Patient Preparation

Surgical Approach

A Pfannenstiel incision is sufficient to treat VUR in children. The urinary bladder is exposed extraperitoneally; the ureter is identified under the medial umbilical ligament (after transection) and marked with a vessel loop.  

Lich-Gregoir Reimplantation:

A submucosal tunnel is achieved by incision of the detrusor (detrusortomy) and closure over the ureter.

Technical Modifications:

The Lich-Gregoir technique can be performed laparoscopically (robotic-assisted) with excellent vision (Weiss et al., 2015).

Postoperative Care after Lich-Gregoir Ureterocystoneostomy

General measures:

Early mobilization, thrombosis prophylaxis depending on age, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesia:

Analgesics with a combination of NSAIDs and opioids.

Catheter:

Quickly remove the transurethral catheter depending on hematuria and possible injury of the mucosa. Control for residual voiding volume.

Complications of Transvesical Ureterocystoneostomy






Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

References

Hinman: Atlas Urologischer Operationen im Kindes- und Erwachsenenalter.

C. Kruppa et al., “Vesicoscopic vs. Open Ureteral Reimplantation According to Cohen and Leadbetter-Politano for Vesicoureteral Reflux.,” J Clin Med., vol. 12, no. 17, 2023, doi: 10.3390/jcm12175686.

H. Riedmiller and E. W. Gerharz, “Antireflux surgery: Lich-Gregoir extravesical ureteric tunnelling.,” BJU int., vol. 101, no. 11, pp. 1467–1482, 2008, doi: 10.1111/j.1464-410X.2008.07683.x.

J. Steffens, E. Stark, B. Haben, and A. Treiyer, “Politano-Leadbetter ureteric reimplantation.,” BJU int., vol. 98, no. 3, pp. 695–712, 2006, doi: 10.1111/j.1464-410X.2006.06407.x.



  Deutsche Version: Harnleiterreimplantation: Technik nach Leadbetter, Lich-Gregoir, Psoas hitch und Boari Lappen