Wrap Plication of Megaureter Around Normal-Sized Ureter for

Complete Duplex System Reimplantations

M. M. C. van den Heijkant,* P. Dik, A. J. Klijn, R. Chrzan, C. F. Kuijper
and T. P. V. M. de Jong
From the Pediatric Renal Center, University Childrens Hospital, University Medical Center Utrecht, Utrecht (MMCvdH, PD, AJK, TPVMdJ)
and Pediatric Renal Center, University Childrens Hospital, Academic Medical Center, University of Amsterdam, Amsterdam
(RC, CFK, TPVMdJ), the Netherlands

Purpose: A duplex collecting system is a common congenital renal tract abnormality associated with different clinical problems. We describe our experience
with ureteral reimplantations of a complete duplex collecting system where 1 megaureter needing recalibration and 1 normal-sized ureter coexisted. Recalibration of the
megaureter was done by wrap plication around the normal-sized ureter.
Materials and Methods: Operative logs and case notes were reviewed of consecutive children with a complete duplex collecting system treated with wrap plication of the megaureter around the normal-sized ureter and reimplantation between 1997 and 2010. Reoperation, vesicoureteral reflux and obstruction rates
were assessed.
Results: A total of 25 children underwent wrap plication and ureteral reimplantation. Of the cases 19 (76%) were completely successful and 6 (24%) needed
reoperation. Three children (12%) had persistent high grade vesicoureteral reflux, 2 (8%) underwent endoscopic correction and 1 (4%) underwent repeat reimplantation of the duplex system. Three children (12%) had postoperative obstruction and 2 (8%) underwent endoscopic incision of the ureteral orifice. In 1 child
(4%) a nonfunctioning lower moiety of the kidney developed, which was managed
by heminephrectomy.
Conclusions: Wrap plication of a megaureter around the normal-sized ureter
before reimplantation seems to be a relatively safe method in the surgical management of children with a complete duplex collecting system of the kidney.
Sufficient spatulation of the lower pole ureter seems to be crucial.

Abbreviations
and Acronyms
AP antibiotic prophylaxis
DCS duplex collecting system
DMSA dimercapto-succinic
acid
EC endoscopic correction
MAG3 mercaptoacetyltriglycine
US ultrasound
UTI urinary tract infections
VCUG voiding cystourethrogram
VUDS videourodynamics
VUR vesicoureteral reflux
Accepted for publication April 24, 2012.
* Correspondence: Pediatric Renal Center,
University Medical Center Utrecht, Lundlaan 6,
3584 EA Utrecht, The Netherlands (telephone:
31-0-887554075; FAX: 31-0-887555312; e-mail:
m.m.c.vandenheijkant@umcutrecht.nl).

Key Words: congenital abnormalities, replantation, ureter, urinary tract,

urologic surgical procedures
A duplex collecting system is a common
congenital urinary tract variation that
can cause various clinical problems.1
Most duplex collecting systems are
asymptomatic and are found incidentally
due to the increased frequency of prenatal ultrasound investigation.2 However,
in cases of complete duplication combined with vesicoureteral reflux in 1 moiety, obstructive megaureter or ureteroceles symptomatic urinary tract infec-

tions are more common, and in girls dribbling incontinence can be a symptom of
an ectopic upper pole ureter.3 In case of
severe reflux into 1 moiety or an obstructive upper pole megaureter doublebarreled ureteral reimplantation may be
required. When 1 megaureter exists,
ureteral recalibration will be necessary
to achieve an adequate width-to-length
ratio of the reimplanted intramural
ureter.

0022-5347/13/1891-0295/0
THE JOURNAL OF UROLOGY
2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION

http://dx.doi.org/10.1016/j.juro.2012.09.004
Vol. 189, 295-299, January 2013
RESEARCH, INC.
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295

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WRAP PLICATION OF MEGAURETER FOR DUPLEX SYSTEM REIMPLANTATIONS

We describe our experience with double-barreled

ureteral reimplantation of a complete DCS where 1
megaureter needing recalibration and 1 normal-sized
ureter coexisted. Recalibration of the megaureter was
done by wrap plication around the normal-sized ureter.

MATERIALS AND METHODS

We reviewed the operative records of consecutive children
with complete DCS and a dilated ureter undergoing wrap
plication of the megaureter around the normal-sized ureter and subsequent reimplantation between 1997 and
2010. A total of 25 children fulfilled inclusion criteria.
Medical records and radiological reports of the children
were reviewed to collect preoperative data on indication
for surgical intervention, symptoms and severity of dilatation of the ureters on ultrasound, VCUG/VUDS and
DMSA/MAG3 scans. Operative report and clinical course
during hospital stay were assessed.
All children were seen at 3 months postoperatively for
assessment of clinical symptoms and to undergo US. In
case of preoperative obstruction and postoperative dilatation
on US, defined as an anteroposterior diameter of the renal
aperture that was increased or unchanged compared to preoperative status, a MAG3 scan was performed. In cases of
symptomatic UTI (defined as symptoms and more than 10.5
bacteriuria 2 times yearly or more) with preoperative vesicoureteral reflux on VCUG postoperative VCUG/VUDS was
performed to rule out persistent reflux. All children received
antibiotic prophylaxis for 3 months. VCUG was routinely
performed when the child was 1, 5 and 6 years old.
In all patients obstruction, VUR and reoperation rates
were assessed. Most patients were sent back to their referring pediatrician or pediatric nephrologist after 1 year
for further followup to assess kidney and lower UTI. Complications were assessed according to the Clavien-Dindo
classification system.4
At induction of anesthesia patients were given 25
mg/kg amoxicillin-clavulanic acid, which was repeated
twice in the first 24 hours. Cystoscopy was performed to
assess aspect and position of the ureteral orifices, and
shape of the bladder neck and trigone, and to assess other
pathological conditions such as ectopic ureterocele, bladder neck anomalies and any urethral obstruction in boys.
A lower abdominal transverse incision with transverse
opening of the fascia and longitudinal splitting of the
rectus muscles in the midline was performed to expose
and open the bladder. In case of a ureterocele the ureterocele was excised completely, followed by reconstruction of
the bladder neck.5 Next, both ureters were dissected from
inside the bladder. The megaureter was plicated around
the normal-sized ureter using four 5-zero polyglycolic acid
sutures, with a 10Fr splint in the megaureter and a 6Fr
splint in the normal-sized ureter to secure this ureter (see
figure). The normal-sized ureter was spatulated over 5 to
10 mm to prevent stricture, and the spatulation was secured with four 6-zero polyglycolic acid sutures. In both
ureters a 4Fr or 6Fr external ureteral splint was inserted,
and the ureteral complex (consisting of both ureters) was
reimplanted into the bladder.
A transtrigonal Cohen reimplantation or modified Politano-Leadbetter reimplantation was performed. The ure-

Wrap recalibration of megaureter around normal-sized ureter in

duplex collecting system, with sufficient spatulation in normalsized ureter.

teral complex was fixed to the detrusor muscle by 2, 5-zero

polyglycolic acid sutures and covered by mucosa. Routinely a suprapubic catheter was placed for optimal postoperative bladder drainage for 5 to 6 days.
Postoperatively all patients received 0.4 mg/kg oxybutynin daily in 3 administrations during catheterization to
avoid bladder spasms. The ureteral splints were removed
4 to 5 days postoperatively and AP was continued for at
least 3 months.

RESULTS
A total of 13 males and 12 females with DCS underwent wrap recalibration and double-barreled ureteral reimplantation between 1997 and 2010. Median age at surgery was 12 months (range 1 to 79)
and median followup was 25 months (3 to 148).
Patient characteristics are presented in table 1. A
total of 11 children presented with prenatal hydronephrosis, 8 did not have prenatal hydronephrosis
and 6 had no prenatal US available.
Preoperatively 8 children not on AP had a UTI, 6
on AP had a breakthrough UTI, 5 on AP had no UTI,
2 not on AP had no UTI and in 4 the incidence of UTI
was unknown. In 6 patients (24%) the indication for
surgery was primary obstructive megaureter of the
upper moiety of the duplex system with ureterocele
and decreased split function on MAG3 of the upper
moiety of the kidney. In 5 of these patients there was
no VUR in the lower pole ureter, and in 1 there was an
obstructive upper pole ureter with ureterocele, as well
as VUR grade II of the lower pole. In these 6 patients
wrap plication of the upper pole was done around the
lower pole ureter. In 19 patients (76%) the indication
for surgery was symptomatic UTI with primary grade
IV to V reflux into the lower pole of the kidney. In
these patients wrap plication of the lower pole ureter
was done around the normal-sized upper pole ureter.

WRAP PLICATION OF MEGAURETER FOR DUPLEX SYSTEM REIMPLANTATIONS

Table 1. Patient characteristics

No. gender:
M
F
Median mos age at surgery (range)
Median mos followup (range)
Diagnosis:
Complete duplex system
VUR of lower pole
Concurrent ureterocele upper pole obstruction
Concurrent urethral obstruction in boys
Lt duplex system
Rt duplex system
Bilat duplex system

13
12
12 (179)
25 (3148)
25
19
6
6
12
11
2

Of the 25 children 23 underwent a modified Politano-Leadbetter reimplantation of the ureteral complex

and 2 underwent transtrigonal Cohen reimplantation.
The latter 2 patients had no postoperative complications. Six children with ectopic ureteroceles running
into the bladder neck underwent excision of the ureterocele with bladder neck reconstruction, and 6 boys
had concurrent urethral obstruction by cystoscopy.
One girl had previously undergone an unsuccessful
endoscopic correction of VUR of the lower pole ureter.
There were no intraoperative complications. Postoperative hospitalization ranged from 3 to 14 days
(median 5). In the direct postoperative period 2 of
the 25 children (8%) needed endoscopic insertion of a
Double-J catheter for 3 weeks after removal of the
ureteral splint under general anesthesia due to persistent dilatation on US (Clavien grade 3b). An upper respiratory tract infection developed in 1 child
(4%) with prolonged hospitalization (Clavien grade
2, pharmacological treatment needed).
Of the 25 patients 21 (84%) had postoperative
imaging of VUR (VCUG or VUDS) available, including 9 (43%) with persistent VUR of the lower pole
ureter, 2 with downgraded VUR of the lower pole
ureter (from grade III preoperatively to grade II
postoperatively), 3 with unchanged VUR (grade II),
2 with more severe VUR of the lower pole ureter (1
from no VUR to grade III and 1 from grade II to
grade IV), and 1 with preoperative obstruction of the
upper pole ureter and VUR of the upper pole ureter
postoperatively (grade II). One patient had postoperative VUR of the lower pole ureter (grade II) as
well as preoperative VUR (grade unknown). Of 21
cases where postoperative VUR was assessed 11
(52%) did not have VUR. Four patients did not have
a postoperative VCUG available. During followup 19
children (76%) did not need reoperation. Of these
patients 13 had no clinical symptoms and no postoperative VUR, while 6 had persistent low grade
VUR without clinical symptoms and, therefore, did
not undergo surgical intervention. Six children
(24%) needed reoperation.

297

Table 2 outlines the reoperation rates and Clavien-Dindo grades of surgical complications. Two
children (8%) underwent EC of VUR of the lower
pole ureter because of persistent high grade reflux
(grade IV) postoperatively (Clavien grade 3b), both
of whom had grade II reflux preoperatively of the
lower pole of the kidney and no upper pole obstruction. Two children (8%) had persistent dilatation on
US and obstruction on MAG3 scan due to obstruction of the ureteral orifices of the duplex system and,
therefore, underwent endoscopic incision (Clavien
grade 3b). Both patients had preoperative grade IV
reflux of the lower pole ureter and no upper pole
obstruction. One child (4%) underwent repeat reimplantation of the duplex system (Clavien grade 3b).
This patient had a preoperative obstruction due to
an ectopic upper pole ureter into the seminal vesicles. A nonfunctioning lower pole moiety of the kidney developed in 1 child (4%), which was treated
with heminephrectomy (Clavien grade 4a, single organ dysfunction). Preoperatively this patient had an
upper pole ureter ending into an ectopic ureterocele
and VUR (grade II) of the lower pole ureter.

DISCUSSION
DCS is the most common anomaly of the urinary
tract and can lead to various clinical problems.6 9
During the embryological period complete ureteral
duplication occurs when 2 ureteral buds arise from
the same wolffian duct. Defined by the WeigertMeyer law, the lower pole ureter separates from the
wolffian duct in an earlier stage, resulting in superior and lateral migration during the growth of the
urogenital sinus.10,11 The upper pole of the duplex
kidney is drained by the cephalad ureter, and the
lower pole by the caudal ureter. After migration of
the wolffian duct the upper pole ureter is inserted
into the bladder more medially and inferiorly than
the lower pole ureter. Therefore, the lower pole ureter tends to have a shorter submucosal tunnel and
reflux occurs more frequently. However, reflux to the
upper pole system is often present when the ureter
opens ectopically at the bladder neck or in the urethra.
DCS can be unilateral or bilateral and may be
associated with other congenital abnormalities of

Table 2. Reoperation rates after wrap plication and

reimplantation of duplex system
No. (%)
EC of persistent high grade VUR lower pole ureter
Endoscopic incision of ureteral orifices in DCS
Repeat reimplantation of DCS
Heminephrectomy of nonfunctioning lower pole moiety kidney
Total reoperations/total group

2
2
1
1

(8)
(8)
(4)
(4)

6/25 (24)

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WRAP PLICATION OF MEGAURETER FOR DUPLEX SYSTEM REIMPLANTATIONS

the renal tract, such as ectopic ureters and ureteroceles. Due to a higher incidence of higher grades of
reflux in duplicated systems and concomitant other
congenital anomalies, surgical intervention is often
required.7 Management of complete DCS depends
on the severity of ureteral dilatation, split function
of both moieties of the kidney on DMSA scan, severity of VUR found on VCUG and symptomatology.7 In
case of a complete DCS with mild dilatation, good
split function on DMSA scan or low grade reflux
without UTI conservative treatment can be applied
as in nonduplicated systems.6 In complete DCS with
a nonfunctioning upper pole heminephrectomy will
be performed in most cases. With increasing frequency EC of VUR in duplex systems is performed.
However, as in single systems, EC is suitable only
for mild to moderate VUR.12,13
With decreased function of one of the moieties of
the duplex collecting system kidney on DMSA scan
or a MAG3 scan with dilatation due to obstruction or
high grade reflux, or in case of breakthrough UTIs,
surgical reimplantation of both ureters will often be
done.7 Chacko et al described in an 8-year retrospective review of 193 cases of complete DCS use of
ipsilateral ureteroureterostomy in the surgical management of the severely dilated ureters.14
In case of reimplantation of a megaureter it is
important to have an adequate width-to-length ratio
of the new intramural ureter, and ureteral tapering
or plication is often needed to decrease the width of
the ureter. In the last few decades several operative
techniques have been used. Hendren described the
excisional wedge technique in which a lateral strip
of abundant ureteral tissue is excised, with overall
success rates of 74% to 90%.1518 This technique has
several potential drawbacks. Ureteral blood supply
is potentially compromised with the risk of secondary
stenosis. Due to disruption of the ureteral lumen, urinary leakage can occur, which can cause inflammation
and scarring. To avoid these possible complications, a
prolonged period of stenting is required.15 Therefore,
plication techniques were developed.
Kalicinski et al first described a folding technique
in which the distal ureter was tailored and redundant tissue was plicated around the ureter.17 Starr
later described another plication technique in which
inverting stitches were placed in the distal ureter.19
Several studies have compared excisional tapering with a plication technique. In a retrospective
study wedge resection was compared to infolding by
the Kalicinski technique.18 This investigation resulted in a 95% success rate for the plication group
and a 90% success rate for the wedge resection
group. However, due to selection bias, only smaller
caliber ureters were infolded and a wedge resection
was performed in wider ureters that appeared too
bulky to be reimplanted. In the infolding group a

slightly higher percentage showed postoperative

VUR (5%), compared to the resected group (3%).
Hydronephrosis improved or stayed the same in the
infolded group but worsened in 6% of the resected
group. The Kalicinski technique demonstrated success rates of 93% to 96%.17,20 23
Fretz et al studied the long-term results of the
Starr method of plication in 16 primary obstructive
megaureters, and observed no postoperative obstruction and 1 ureter exhibiting persistent VUR.23
In all studies plication of megaureters seems to be
safer than performing a wedge resection.
Yamazaki et al described their experience in 2
cases in which they performed excision of a ureterocele and plicated the dilated upper pole ureter
around the ureteral common sheath in a duplex
system.24 This plication procedure may be complicated by excessive bulk of tissue at the reimplantation site. Therefore, our group developed a technique
in which we plicate the upper pole ureter around the
lower pole ureter. In our series a dysfunctional lower
pole moiety of the kidney developed in 1 child and 2
children needed endoscopic incision of an obstructed
ureteral orifice. In retrospect, in these children we
assume that lack of adequate spatulation of the normal-sized distal ureter could be the cause of the
obstruction. Although we secured both ureters with
stents during wrap plication, ischemia due to a too
tight plication could also be an explanation. Two
children had persistent high grade VUR of the lower
pole ureter, which was corrected successfully by EC,
and 1 child needed repeat reimplantation due to
persistent high grade VUR and persistent UTI.
A limitation of this study is the retrospective nature. To assess structurally the success of this technique, routine postoperative VCUG should be performed in all children and ideally long-term followup
of these children should be performed at our hospital. We describe how we dealt with these patients in
daily practice. We try to prevent performing VCUG
between ages 1, 5 and 6 years for psychological reasons. Four patients (16%) had no postoperative
VCUG available. In these patients postoperative renal ultrasound did not reveal a dilated ureter, so
these patients would not have high grade VUR. At
best, 15 of 25 patients (60%) had no (dilating) postoperative VUR. In terms of postoperative VUR, the
procedure has a moderate success rate. Other procedures have similar outcomes in this complex group
of patients. The advantage of a less bulky ureteral
complex into the bladder outweighs the disadvantage of postoperative VUR.
In conclusion, wrap plication of a megaureter
around the other ureter before reimplantation seems
to be a relatively safe method in the surgical management of children with a complete duplex collecting
system of the kidney.

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299

REFERENCES
1. Thomas DF: Fetal urology and prenatal diagnosis.
In: Kelalis-King-Belman Textbook of Clinical Pediatric Urology. Boca Raton, Florida: Taylor &
Francis 2007; chapt 13.
2. Kang AH and Bruner JP: Antenatal ultrasonographic development of ureteroceles. Implications for management. Fetal Diagn Ther 1998; 13:
157.
3. Siomou E, Papadopoulou F and Kollios KD: Duplex collecting system diagnosed during the first
6 years of life after a first urinary tract infection:
a study of 63 children. J Urol 2006; 175: 678.
4. Clavien PA, Barkun J and de Oliveira ML: The
Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250:
187.

8. Hawthorne AB: The embryological and clinical

aspect of double ureter. Can Med Assoc J 1936;
34: 21.

16. Bjordal R, Eek S and Knutrud O: Early reconstruction of wide ureter in children. Urology 1978; 11:
326.

9. Nation EF: Duplication of the kidney and ureter: a

statistical study of 230 new cases. J Urol 1944;
51: 456.

17. Kalicinski ZH, Kansy J and Kotarbinska B: Surgery

of megauretersmodification of Hendrens operation. J Pediatr Surg 1977; 12: 183.

10. Meyer R: Normal and abnormal development of

the ureter in the human embryo; a mechanistic
consideration. Anat Rec 1946; 96: 355.
11. Weigert C: Uebeteinige bil dunfehter der uretern.
Virchows Arch 1977; 70: 490.
12. Hensle TW, Reiley EA and Ritch C: The clinical
utility and safety of the endoscopic treatment of
vesicoureteral reflux in patients with duplex ureters. J Pediatr Urol 2010; 6: 15.

5. Beganovic A, Klijn AJ and Dik P: Ectopic ureterocele: long-term results of open surgical therapy in
54 patients. J Urol 2007; 178: 251.

13. Rossini CJ, Moriarty KP and Courtney RA: Endoscopic treatment with Deflux for refluxing duplex
systems. J Laparoendosc Adv Surg Tech A 2009;
19: 679.

6. Afshar K, Papanikolaou F, Malek R et al: Vesicoureteral reflux and complete ureteral duplication. Conservative or surgical management?
J Urol 2005; 173: 1725.

14. Chacko JK, Koyle MA and Mingin GC: Ipsilateral

ureteroureterostomy in the surgical management
of the severely dilated ureter in ureteral duplication. J Urol 2007; 178: 1689.

7. Whitten SM and Wilcox DT: Duplex systems.

Prenat Diagn 2001; 21: 952.

15. Hendren WH: Complications of megaureter repair

in children. J Urol 1975; 113: 238.

18. Parrott TS, Woodard JR and Wolpert J: Ureteral

tailoring: a comparison of wedge resection with
infolding. J Urol 1990; 144: 328.
19. Starr A: Ureteral plication. A new concept in
ureteral tailoring for megaureter. Invest Urol
1979; 17: 153.
20. Bakker HH, Scholtmeijer RJ and Klopper PJ: Comparison of 2 different tapering techniques in
megaureters. J Urol 1988; 140: 1237.
21. Ehrlich RM: The ureteral folding technique for
megaureter surgery. J Urol 1985; 134: 668.
22. Perdzynski W and Kalicinski ZH: Long-term results after megaureter folding in children. J Pediatr Surg 1996; 31: 1211.
23. Fretz PC, Austin JC and Cooper C: Long-term
outcome analysis of Starr plication for primary
obstructive megaureters. J Urol 2004; 172: 703.
24. Yamazaki Y, Setoguchi K and Yago R: Common
sheath reimplantation with ureteral plication: a
useful technique for the management of ectopic
ureterocele. Int J Urol 1999; 6: 532.