Ureteric reimplantation: a history of the development of surgical techniques

The earliest attempt at ureteric reimplantation was reportedly by Nussbaum in 1876 [1]. In 1903, Sampson conducted several experiments in dogs, after which he also described the case of a woman in whom he reimplanted the left ureter via an extraperitoneal approach on 20 July 1903 and the right on 8 September 1903, using local anaesthesia [2]. Up to 1932, the ectopic ureter, para-ureteric diverticula and `congenital' were the reasons given to proceed to ureteric reimplantation [1], and in his paper in 1933 Beer [1] stated, `Considerable doubt exists as to whether it is worthwhile attempting to conserve a kidney by reimplanting its ureter in the bladder, provided the other kidney was functioning normally'. Beer also described the use of indigo to assess the function of the kidney and the advent of IVU to better study these kidneys. Many techniques have subsequently been suggested, including drawing the ureter through the original ureteric channel and fastening it to both the inside and outside of the bladder (Patton 1939, cited in [3]) or bringing the ureter directly through the bladder wall, splitting and securing the ureter by sutures placed through the bladder with knots on the outside (Toulson 1939, in [3]). Stevens and Marshall [3] modi®ed the approach of the last two authors, producing a report of 10 patients in whom they performed a ureteric reimplantation. They used a technique which involved reinsertion of the ureter into both a separate muscle and mucosal ori®ce, adding a submucosal tunnel: alternatively, division of the transvesical bar with an hour-glass deformity of the bladder was thought to be curative in Pranther's case, in 1944 [4]. Before 1950, many of the operations for reimplanting the ureter were for disease other than VUR. This was changed when the Hutch-I procedure was ®rst used in May 1950; the operation consists of intravesical mobilization of the ureter, leaving the attachment to the mucosa intact, and the ureter ultimately lying on top of the mucosa (Fig. 1). The initial presentation was of nine paraplegic patients operated on over one year, after which six were cured of their VUR [5]. The Hutch-II procedure involved closure of the mucosa over the transplanted ureter [6]. In 1955, Jewitt suggested dividing the ureter outside the bladder and bringing the ureter through a tunnel to lie near its initial ori®ce; the distal ureter was sutured on top of the bladder mucosa. The second Jewitt technique was intended for ureters that were not tortuous and was similar to the Hutch-I technique, i.e. intravesical mobilization, with the ori®ce being left intact; it differs from the Hutch procedure in that the bladder muscle was closed under the ureter, but the mucosa was closed over the distal ureter [7]. In 1958, Fuqua et al. [8] presented a small series of cases in which they used a minor modi®cation of the Hutch operation, with only 80% success; the poor success rate lead to further exploration of alternative approaches. Several new concepts then appeared; in 1957 Grey et al. [9] discussed the results of a series of dog experiments in which the ureter was dilated by tying it around a ®ne cannula; they then conducted three different types of ureteric reimplantation: (a) a hook was used to intussuscept the ureter, after which it was reimplanted into the dome of the bladder; (b) the ureter was mobilized inside the bladder, a catheter was placed into the ureter and trans®xed, facilitating intussusception of the distal ureter in situ; (c) an intussuscepted valve was created part way up the ureter. The latter operation was used in two cases, with no success. The techniques of Grey et al. have not otherwise been reported (Fig. 2). The ®rst widely used and still popular ureteric reimplantation technique was introduced by Politano and Leadbetter, who reported a series of patients in 1958 [10]. The procedure involves dissecting the ureter from the bladder and then passing the ureter through a more BJU International (2000), 85, 1000±1006