Politano-Leadbetter ureteric reimplantation (step by step operation series)
In this series we present an easy illustration to different operative techniques in urology
The many antireﬂux procedures currently in use have a success rate of 95% . they all attempt to create a submucosal tunnel which is four times longer than the width of the ureter being reimplanted. Of the many intra- and extravesical techniques in use, the Politano-Leadbetter, Lich-Gregoir and Cohen have gained the greatest popularity over the past four decades.
The main indication for this procedure is bilateral reﬂux, which can be surgically corrected at one session . It creates a neo-oriﬁce in an anatomically correct position, which is easily accessible for endourological manipulations . There is no risk of lesions to the pelvic ganglion, with persistent neurogenic bladder dysfunction, if the extravesical preparation is made close to the ureter in the layer of the meso-ureter.
• Uncomplicated vesico-renal reﬂux grade II–V.
• Before puberty in undilated single or double systems.
• Bilateral reﬂux.
PREOPERATIVE DIAGNOSTIC PROCEDURES
• Urine culture.
• Kidney and bladder ultrasonography, exclusion of residual urine.
• MAG 3 clearance.
• Exclude ureteric obstruction
Pfannenstiel incision. Longitudinal incision of rectus fascia.
Longitudinal bladder dome incision.
Bilateral ﬁxation of the bladder wall at rectus fascia. Insertion and ﬁxation of an ureteric stent.
Circumferential incision of the ureteric oriﬁce.
Distal ureterolysis; the preparation is made close to the ureter in the layer of the meso-ureter.
Transvesical mobilization of the adherent peritoneum from the distal ureter using a Langenbeck retractor for better visualization.
Transvesical insertion of an Overholt close to the bladder wall 3 cm above the old oriﬁce incision of the bladder mucosa to create a neo-hiatus.
After preparation of a wide neo-hiatus, grasping of a free suture as a guide rail for the ureter
Retraction of one suture end into the bladder. Fixation with the stay suture of the ureteric oriﬁce after stent removal
Passage of the extravesically mobilized ureter through the wide neo-hiatus pulling at the free suture end intravesically.
Transvesical transposition of the distal ureter. Submucosal tunnel preparation from the old to the new hiatus
Closure of the bladder wall defect (former position of the old oriﬁce) using three sutures.
Submucosal transposition of the distal ureter.
Fixation of the oriﬁce at initial position after resection of a dysplastic ureteric segment. Closure of the bladder mucosa over the reimplanted ureter.
Wound closure. Drainage, ureteric stent and two cystostomies in place
• Remove the wound drain on day 3.
• Remove the ﬁrst cystostomy when urine is clear on day 3–5.
• Remove the ﬁrst ureteric stent after 8 days, the second after 9 days together with the second cystostomy.
• Kidney ultrasonography after removing the stents.
• Antibiotic treatment (cephalosporin) during stenting.
• Antibiotic prophylaxis is given for 2 weeks in uncomplicated cases, otherwise for 3 months.
• Analgesic therapy