title: Evaluation and outcome of the distal ureteral stump after nephro-ureterectomy in children. A comparison between laparoscopy and retroperitoneoscopy.
abstract: BACKGROUND
  In children with a poorly functioning kidney due to vesicoureteral reflux (VUR) or ureteropelvic junction obstruction, management is by nephrectomy with total or proximal ureterectomy. The complete removal of all the ureter minimizes the risk of future morbidity associated with the distal ureteral stump (DUS), including febrile urinary tract infections (UTIs), lower quadrant pain and hematuria, the so-called ureteral stump syndrome.
  
  
  OBJECTIVE
  To assess the outcome of the DUS after nephroureterectomy, we analyzed our recent experience of nephrectomy performed via retroperitoneoscopy and via laparoscopy.
  
  
  METHODS
  The records of 21 consecutive patients (median age 3.5 years, range 1-10 years) who underwent nephroureterectomy via laparoscopy or via retroperitoneoscopy were retrospectively reviewed for symptoms caused by DUS and their management. Nephrectomy was undertaken for a poorly functioning dysplastic (4), scarred from VUR (10) or hydronephrotic (7) kidney. In the laparoscopic group (11 pts), 6 cases required nephrectomy for reflux while 5 patients were operated for hydronephrotic or dysplastic non-functioning kidney. In the retroperitoneoscopic group (10 pts), nephrectomy was performed for reflux in 4 cases versus 6 patients affected by hydronephrotic or dysplastic non-functioning kidney. The patients were evaluated using ultrasound (US) to check DUS length and clinically to evaluate symptoms due to a symptomatic DUS.
  
  
  RESULTS
  The average length of surgery was 50 min for laparoscopy and 80 min for retroperitoneoscopy. The average of follow-up was 5 years. The length of DUS after laparoscopic nephrectomy was shorter (range 3-7 mm, statistically significant) than the DUS after retroperitoneoscopy (range 2-5 cm) (p < 0.001). Laparoscopic patients were all asymptomatic. Two patients, after retroperitoneoscopic nephrectomy, presented with recurrent UTIs; a voiding cystography revealed a VUR on the residual DUS and a redo surgery was performed in both the patients to remove the DUS (Figure).
  
  
  CONCLUSIONS
  Several authors have stated that, in case of subtotal ureterectomy, the incidence of symptomatic DUS after nephrectomy for high-grade vesicoureteric reflux is low. However, in our series, the incidence of symptomatic DUS after nephroureterectomy was not insignificant (2/21, 9.5%). Symptoms related to a refluxing DUS occurred only in patients undergoing retroperitoneoscopic nephroureterectomy, where the DUS was longer than the DUS detected in laparoscopic patients.
  
  
  CONCLUSIONS
  Considering that laparoscopy permits removal of all the ureter near the bladder dome, in children with non-functioning kidney due to VUR, it is advisable to always perform a laparoscopic rather than a retroperitoneoscopic nephrectomy to prevent problems related to a symptomatic DUS.
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy. Electronic address: x.escolino@libero.it.
authors.forename: Maria
authors.initials: M
authors.lastname: Escolino
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Farina
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Turrà
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Mariapina
authors.initials: M
authors.lastname: Cerulo
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Rosanna
authors.initials: R
authors.lastname: Esposito
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Savanelli
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Settimi
authors.affiliation: Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy.
authors.forename: Ciro
authors.initials: C
authors.lastname: Esposito
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007674:Kidney Diseases / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014513:Ureter / Q000000981:diagnostic imaging / Q000601:surgery*; D014517:Ureteral Obstruction / Q000150:complications* / Q000175:diagnosis; D014567:Urography; D014718:Vesico-Ureteral Reflux / Q000150:complications* / Q000175:diagnosis
keywords: Children; Laparoscopy; Nephro-ureterectomy; Retroperitoneoscopy; Ureteral stump