The Cohen cross-trigonal ureteral reimplantation operation is a well-established open surgical procedure for vesico-ureteric reflux (VUR) disease. The procedure entails the cross reimplantation of one or both ureters, which will open at a new ureteric orifice (UO) located at a region across the bladder trigone [1,2].
This operation is performed to decrease the possibility of persistent VUR by achieving a longer ureteric trans-mural length, that is at least 5 times greater than the ureteric diameter (Paquin’s rule) .
Although various therapeutic options and endoscopic advancements have been described in the management of VUR, the Cohen cross-trigonal ureteral reimplantation operation was the mainstay among surgical options in previous decades. More recent trends are endoscopic management or non-surgical (antibiotic prophylaxis) options [4,5].
Despite these trends, a significant number of children who underwent the Cohen cross-trigonal ureteral reimplantation operation, in the 1980’s and 90’s, are now presenting to urologists as adult patients.
Although better endoscopic training and tips and tricks are now openly available along with the advancements in ureteroscopic miniaturization and technology [6,7], the retrograde access of the crossed reimplanted ureter will always be a potential challenge.
Previously techniques described cystoscopic access via the bladder, which can often be challenging or supra-pubic access of the ureter via the bladder and then subsequent ureteric access via the suprapubic route [8,9,10,11,12,13,14,15,16,17,18,19,20].
To assist with the endoscopic management of these patients, we describe a simple technique of attaining urethral operative ureteral access in the Cohen crossed reimplanted ureter.
Materials and Methods
We report on a simple, novel method, to attain ureteric access in a crossed reimplanted ureter in an adult patient with persistent flank pain, pyonephrosis, and recurrent pyelonephritis that required insertion of a left-sided double J stent. The patient had a history of previous bladder surgery for recurrent urinary tract infections in childhood. Relevant patient consent along with local internal institutional ethics committee approval had been attained (Human Research Ethics Committee Clearance Certificate Number M170157).
Under cystoscopic vision, a suprapubic needle puncture (18 G, 1.3 × 45 mm) was performed in the contralateral bladder quadrant, to allow for an angle of approach into the crossed reimplanted UO. A stiff guidewire with a floppy hydrophilic tip (fig. 1k) was used for insertion and negotiation into the UO. The needle was directed with the bevel facing the desired UO. The guidewire was then inserted into the suprapubic needle passing into the bladder, and the floppy hydrophilic-tip was easily passed into the crossed-reimplanted UO. Guidewire placement was then confirmed up the desired ureter by fluoroscopy screening, and it later confirmed floppy-tip coiling in the left renal pelvis.
The distal end of the guidewire was then passed via the suprapubic tract, into the bladder and subsequently removed through the urethra with cystoscopic grasping forceps (while simultaneously ensuring that the floppy hydrophilic tip was not removed or slipped out of the ureter or renal pelvis). The ureter was then easily straightened with gentle lateral movement of the stiff guidewire. This straightened ureter now easily facilitated ureteros-copy access, retrograde pyelogram studies, and JJ stent insertion in the conventional transurethral method. See fig. 1 (a-k) and fig. 2 (a-d) and attached supplementary video.
Using the conventional, urethral access method, the ureter was easily accessed with the stiff guidewire, and the UO was now aligned in a more orthotopic course. The suprapubic puncture site was not visible at the end of the procedure.
Our method is superior to previously described methods since it allows urethral access for ureteric instrumentation in the standard, conventional manner, but initially uses a suprapubic approach which allows for entrance into the UO with a more conducive angle of insertion. The risk of fluid leakage from the bladder, suprapubic tract, or damage to surrounding anatomical structures is minimized, as a trocar or serial dilation of the suprapubic tract is not needed.
We reviewed all methods of ureteric access after Cohen reimplantation that was described in the literature, and tabulated them in table 1. The search was performed on the Scopus, Web of Science, and PubMed databases using search terms: “ureteric access” or “ureteral access” and “post Cohen cross-trigonal ureteral reimplantation” or “after Cohen cross-trigonal ureteral reimplantation”. Further, a full reference analysis was performed to ascertain other references (techniques) of ureteric access in this group of patients that may have been missed in the original search string. All the previous published methods are described, critically appraised, and tabulated in table 1[8,9,10,11,12,13,14,15,16,17,18,19,20].
Although some previous reports showed that retrograde working access via the transurethral route is possible with the crossed reimplanted ureter, they all accessed this crossed UO, using specialized catheters, or angled guidewires, or experienced flexible ureteroscopy prior to their subsequent transurethral ureteric procedure [11,13,15,19,20]. This is the first description utilizing the benefit of a suprapubic access route into the crossed UO, having the added benefit of a subsequent transurethral retrograde working access approach.
Thus, we have described a simpler method, without the need for specialized equipment or significant expertise. After attaining access via the suprapubic route using a standard 18 G needle, we simplified the working access by grasping the distal remaining portion of the guidewire from the suprapubic tract (fig. 1h), into the bladder, and finally bringing it out of the urethra. This allows for a conventional, almost straightened ureteric working access route (fig. 1j and video supplement).
Certain tips found useful during this technique include: rotating the needle bevel to face the desired UO, suprapubic puncture to be done laterally and opposite the desired ureter, emptying the bladder slightly after the suprapubic puncture to decrease the needle bevel to UO distance, use of a second endoscopic monitor to allow an assistant to direct the cystoscope while the surgeon orientates the suprapubic needle. Further, the use of a stiff guidewire with a floppy tip allows easy manipulation of the ureter after access into the UO is gained. This obviates the need to exchange the guidewire for a stiffer wire for ureteric working access, which may be required in certain cases of semi-rigid ureteroscopy.
A simplified technique to attain a working ureteric access in the Cohen cross-reimplanted ureter is described utilizing materials found in every basic endo-urology unit. Now that the children of the 1980’s and 90’s are well into adulthood, the potential dilemma of accessing the ureter after previous Cohen cross-trigonal ureteral re-implantation will be a more common encounter for the attending urologist.
We are grateful to Mrs. Anna Welman (Department of Surgery, Helen Joseph Hospital, Johannesburg, South Africa) for her secretarial support. We also wish to thank Mr. Devind Peter (Health Sciences Library, University of the Witwatersrand, Johannesburg, South Africa) for assistance with the literature retrieval process, Dr. Grahame HH Smith (The Children’s Hospital at Westmead, Sydney Childrens Hospital Network, Sydney, Australia) for his critical review, Dr. Kalli Spencer and Dr. Julian Hellig (Department of Urology, Helen Joseph Hospital, Johannesburg, South Africa) for their assistance with the case management.
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