MEGAURETER MEGAURETER DR.MOHAMED ASHRAFDR.MOHAMED ASHRAF MOSTAFA MOSTAFA

MS.FRCSMS.FRCS

URETEROVESICAL JUNCTIONURETEROVESICAL JUNCTION

3 Features help the antireflux mechanism•Fixation of the ureter to the trigonal muscle.•Support of the detrusor posteriorly•Compressibility of the ureter.

MEGAURETERMEGAURETER

Ureteral dilatation in Ureteral dilatation in absence of vesical absence of vesical dysfunction or dysfunction or urethral obstruction .urethral obstruction .Males > females .Males > females .Lt. > Rt.Lt. > Rt.

Refluxing Obstructed Non refluxingNon obstructed

Primary Secondary Primary Secondary Primary Secondary

MEGAURETER

Congenitalrefluxingmegaureter

PUVNeurogenic bladder

AdynamicSegmentIntrinsic obst.

PUVNeurogenicBladderExtrinsic obst.

Idiopathic DiabetesInsipedusInfectionResidualPost-obst.dilatation

MEGAURETERMEGAURETER

Megaureterv.u.reflux.

with PUV

Refluxingmegaureterwith

Adult primary megaureter

Adult MegaureterAdult Megaureter

MEGAURETERMEGAURETERMANAGEMENTMANAGEMENT

Conservative .Conservative .

Surgical .Surgical . Pain.Pain. UTI .UTI . Renal impairment.Renal impairment.

U.V.ReimplantationU.V.ReimplantationTechniquesTechniques

Transvesical.Transvesical.Extravesical.Extravesical.Combined.Combined.Suprahiatal or infrahiatal .Suprahiatal or infrahiatal .

URETEROVESICAL REIMPLANTATIONURETEROVESICAL REIMPLANTATIONTECHNIQUESTECHNIQUES

Direct anastomosis.Direct anastomosis.Tunnel implantation .Tunnel implantation .Cuff nipple implantation .Cuff nipple implantation .Bladder flap procedure .Bladder flap procedure .Bladder-elongation psoas hitch procedure.Bladder-elongation psoas hitch procedure.

U.V.ReimplantionU.V.ReimplantionTechniquesTechniques

Stefanovic & coworkers in 1991 addressed the Stefanovic & coworkers in 1991 addressed the need to prevent reflux in the adult undergoing need to prevent reflux in the adult undergoing Ureteral reconstruction.Ureteral reconstruction.In a retrospective review of adults having In a retrospective review of adults having undergone a ureteroneocystostomy, they undergone a ureteroneocystostomy, they concluded there was no difference in the concluded there was no difference in the preservation of renal function or risk of stenosis preservation of renal function or risk of stenosis with antireflux versus reflux procedures .with antireflux versus reflux procedures .Whether a non refluxing anastomosis decreases Whether a non refluxing anastomosis decreases the risk of pyelonephritis in an adult is uncertain.the risk of pyelonephritis in an adult is uncertain.

CASE PRESENTATIONCASE PRESENTATION

38 Years old patients presented with 38 Years old patients presented with repeated left flank pain since long repeated left flank pain since long duration.duration.No history of bilhariziasis or T.B.No history of bilhariziasis or T.B.U/A : normal finding.U/A : normal finding.CBC, BUN , s. creatinine : normal.CBC, BUN , s. creatinine : normal.KUB : No R.O.calculi .KUB : No R.O.calculi .U/S : Lt. back pressure changes.U/S : Lt. back pressure changes.

IVUIVU

Clinical CourseClinical Course

The patient underwent cystoscopy, during The patient underwent cystoscopy, during which ureterocele was excluded .which ureterocele was excluded .On table retrograde study showed a On table retrograde study showed a stenotic segment in distal end of Lt. stenotic segment in distal end of Lt. ureter .ureter .Balloon dilatation was performed .The Balloon dilatation was performed .The internal stent was removed after six weeks internal stent was removed after six weeks

Balloon EndodilationBalloon Endodilation

POST ENDODILATIONPOST ENDODILATIONIVUIVU

Exposure of UreterExposure of Ureter

Exposure of UreterExposure of Ureter

Exposure of UreterExposure of Ureter

U.V.ReimplantationU.V.Reimplantationsplit cuff-nipple techniquesplit cuff-nipple technique

U.V.ReimplantationU.V.ReimplantationSplit cuff-nipple implantationSplit cuff-nipple implantation

Post-Op. cystoscopic viewPost-Op. cystoscopic view

Post Op.Post Op. Ascending Cystography Ascending Cystography

Post Op.Post Op.IVUIVU

Pre & Post - OpPre & Post - Op

Post void

Post void

15 min.

15 min.

Pre-Op

Post-OP