Comparative Outcomes of Primary Ureteral Reimplantation Versus Staged Cutaneous Ureterostomy in Infants Under One with Primary Obstructive Megaureters and Vesicoureteral Reflux: A Multi-Center Analysis

Comparative Outcomes of Primary Ureteral Reimplantation Versus Staged Cutaneous Ureterostomy in Infants Under One with Primary Obstructive Megaureters and Vesicoureteral Reflux: A Multi-Center Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Outcomes of Primary Ureteral Reimplantation Versus Staged Cutaneous Ureterostomy in Infants Under One with Primary Obstructive Megaureters and Vesicoureteral Reflux: A Multi-Center Analysis Moayad Beibooh, Jawdat Jaber, Galiya Raisin, Boris Chertin, Stanislav Kocherov, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7495005/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2025 Read the published version in Pediatric Surgery International → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose: This study evaluates the management and long-term outcomes of pediatric patients under one year of age with primary obstructive megaureters (POM) and vesicoureteral reflux (VUR), comparing primary ureteral reimplantation (PR) to a two-stage approach involving cutaneous ureterostomy (CU) followed by reimplantation. Methods: A multi-institutional study was conducted between 1994 and 2024, including 28 pediatric patients under 12 months of age. Participants were divided into two groups: PR (n=14) and CU (n=14). Comprehensive preoperative assessments, including renal ultrasound, voiding cystourethrography, and radionuclide diuretic renal scans, were performed. Surgical indications were based on recurrent UTIs, impaired renal function, or progressive hydronephrosis. Results: No significant difference in hydroureteronephrosis grade (SFU) was observed between the two groups (p < 0.05). In the PR group, two children required additional surgeries due to recurrent UTIs. Similarly, in the CU group, two children underwent subsequent ureteral reimplantation. The mean age at primary surgery was 6.9 months for the PR group, compared to 4 months for ureterostomy in the CU group (p < 0.05). The average operation time was 110.5 minutes for PR, versus 64 minutes for CU (p < 0.05). Overall, more complications occurred in the group of children with CU until a definitive repair was performed. Conclusions: Both primary ureteral reimplantation and the two-stage approach with cutaneous ureterostomy followed by reimplantation demonstrated effective outcomes in managing POM and VUR in infants. Given the findings, primary ureteral reimplantation may be considered a safe and effective approach in infants under one year old with these conditions. Antenatal urinary tract dilatation primary obstructive megaureter vesicoureteral reflux ureteral reimplantation cutaneous ureterostomy pediatric urology Introduction Urinary tract dilatation (UTD) is the second most frequently diagnosed prenatal anomaly, affecting approximately 1–2% of fetuses [ 1 ]. The causes of UTD vary, with a transient form occurring in 50–70% of cases and resolving spontaneously over time. Among the known etiologies, ureteropelvic junction obstruction (UPJO) is the most common cause of antenatal UTD, followed by vesicoureteral reflux (VUR) in 10–40% of cases, and ureterovesical junction obstruction (UVJO) in 5–15% of cases [ 1 ]. Obstructive megaureter is defined as a ureter diameter exceeding 7 mm. For children with grade III–V VUR, the European Association of Urology (EAU) guidelines recommend initial antibiotic prophylaxis. However, for those with high-grade VUR, surgical options such as ureteral reimplantation should be considered [ 2 ]. In symptomatic patients, clinical signs such as pain, recurrent urinary tract infections (UTIs) despite antibiotic prophylaxis, or worsening UTD, along with a differential renal function below 40% or a progressive decline on serial renograms, may indicate the need for surgical intervention [ 3 ]. A range of treatment options are available, with the choice influenced by the child’s overall health, age, presence of other malformations, and the severity of the condition [ 1 ]. Depending on VUR severity, minimally invasive procedures like endoscopic correction can be considered. We have previously described our experience in the treatment of more than 1300 reimplantations due to VUR and primary obstructive megaureter (POM) [ 4 ]. In cases requiring surgery during infancy, the approach may involve primary ureteral reimplantation (PR) or a staged procedure, which includes an initial cutaneous ureterostomy (CU) followed by delayed reimplantation. The rationale for the two-stage procedure is to reduce the complexity and duration of the first surgery in infancy. The British Association of Pediatric Urologists suggests deferring definitive repair until the child reaches one year of age, using temporizing interventions in the meantime [ 3 ]. However, this recommendation lacks strong supporting evidence and exposes the child to additional procedures. CU is associated with risks such as stomal stenosis (8–22%), febrile UTIs (31%), and pyelonephritis [ 3 ]. Few studies have directly compared the safety, efficacy, and long-term outcomes of primary definitive repair versus a staged approach in infants under 12 months with POM [ 5 ]. In this multicenter study, we aim to evaluate the management and long-term outcomes of pediatric patients under one year of age with POM and VUR who underwent either PR or a two-stage procedure (CU followed by reimplantation). Our hypothesis is that PR is a safe and effective treatment in infancy compared to the staged approach. Materials and Methods This multi-institutional study includes all pediatric patients under 12 months who underwent either PR or CU for POM or VUR between 1994 and 2024 across two medical centers, with ethical approval from the respective institutional review boards of both centers. Perioperative and follow-up data were meticulously collected and are presented in Table 1. Perioperative and follow-up data were meticulously collected for each patient. The preoperative assessment included a comprehensive history, physical examination, urinalysis, urine culture, renal ultrasound (US), radionuclide diuretic renal scan (MAG3), and voiding cystourethrography (VCUG). Surgical indications for the POM group were based on the British Association of Pediatric Urologists (BAPU) consensus guidelines and included recurrent UTIs, impaired renal function (with a relative function of less than 40% on MAG3 scans), deterioration of function (greater than 10% worsening on consecutive MAG3 scans), or progressive hydronephrosis and/or hydroureter [ 3 ]. For the VUR group, indications for surgery included recurrent febrile UTIs despite prophylactic antibiotics, or evidence of obstructive refluxing megaureter supported by existence of beak sign on the VCUG images accompanied by deterioration of the renal function or break through infections while on antibiotic prophylaxis. Surgical Techniques for Ureteral Reimplantation Open Ureteral Reimplantation The LEADBETTER-POLITANO method was utilized in our institutions. The affected ureter is mobilized and electrically dissected intravesically. A submucosal tunnel is created, and the ureter is fixed to the bladder muscle after slight shortening. Robotic-Assisted Laparoscopic Ureteral Reimplantation (RALUR) Using the Da Vinci Xi platform, a transperitoneal approach is employed, following the Lich-Gregoir method [ 6 , 7 ]. The patient is positioned supine, and general anesthesia is induced, often with caudal or quadratus lumborum blocks [ 8 ]. The procedure begins with trocar placement (8-mm camera port, two 8-mm working ports), The distal ureter is dissected to the UVJ with particular attention to avoiding damage to pelvic nerve branches. Once the tunnel is created, the ureter is placed into the detrusor muscle, and the tunnel is sutured over it. Special care is taken to avoid injury to the vas deferens. No external drains or prophylactic antibiotics are used postoperatively. Robotic-Assisted Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation (RADECUR) This technique is used for complex cases as we previously described. [ 4 ]. A transverse detrusorrhaphy is performed on the ipsilateral side of the contralateral ureter. The ureter is tailored when needed, and a bladder-ureter anastomosis is created using Maxon 4 − 0 sutures over a double-J stent. Detrusorrhaphy is closed with a running V-Lock suture. Delayed Staged Repair (DSR) Infants undergo CU to drain the obstructed system. Extraperitoneal exposure is achieved via a modified Gibson incision. After transecting the ureter, a lateral ureteral stoma is created, which is left intubated during the early postoperative course. After a year, a definitive repair with intravesical reimplantation is performed. The urethral catheter is removed on day 1. In those children who required bilateral CU bladder cycling program was initiated following procedure in order to avoid dry bladder and allow normal bladder capacity development and continued till definitive treatment. Statistical Analysis Categorical data were analyzed using the Fisher exact or chi-square test, with significance at p < 0.05. Statistical evaluations were conducted using GraphPad Prism version 6.01. Results Twenty-eight children with UTD of varying etiology were included in our study. Fourteen underwent PR, and fourteen underwent CU as part of a two-stage approach. Operative and postoperative data are presented in Table 2. Preoperative both groups had a high proportion of severe hydronephrosis, as classified by the Society for Fetal Urology (SFU) grading system, with the CU group having slightly more severe cases 9 SFU IV und 4 SFU III vs. 7 SFU IV und 3 SFU III in the PR group. At 1-Year Follow-Up both groups showed improvement, with many patients downgraded to SFU I or II. Also, both groups had patients with normal US findings postoperatively (1 in the PR group and 2 in the CU group). After PR, we observed a significant reduction in SFU grade in our patient cohort at the 1-year follow-up (p < 0.05). Two children developed recurrent UTIs due to underlying persistent VUR despite prophylactic antibiotics, requiring two additional surgeries in the form of endoscopic VUR correction. Similarly, after CU, we observed a significant reduction in SFU grade at 1-year follow-up (p < 0.05). In two children, moderate-severe hydronephrosis was still detectable postoperatively. One child with recurrent UTIs despite prophylactic antibiotic treatment was found to have an additional UVJ stenosis on the contralateral side and underwent bilateral open ureter reimplantation at the age of 3. The second child developed two episodes of idiopathic urinary retention. Subsequently, an open ureteral reimplantation was performed due to de novo VUR on the contralateral side. When comparing the SFU grades between the two groups, no statistically significant difference was found both preoperatively and at 1 year postoperatively. In the PR group, ureteral tapering was performed in 5/14 cases, compared to none in the comparison group. Ureteral diameter was documented only in isolated cases, so we decided not to conduct further analysis on this parameter. Surgery in the PR group was performed at a mean age of 6.9 months, compared to 4 months in the CU group (p < 0.05). Regarding the duration of operation, the procedure in the PR group took an average of 110.5 minutes, compared to 64 minutes in the CU group (p < 0.05). Additionally, there was a statistically significant difference in the mean hospital stay, with 6.4 days in the PR group versus 4.1 days in the CU group (p < 0.05). A postnatal impaired kidney function (abnormal creatinine, GFR was not routinely estimated) was observed in two children in each group. In the case of one child in each group, the kidney function normalized after hydration, allowing the surgery to be delayed and performed electively. The second child in the PR group had a single kidney with POM and UPJS. Initially, a nephrostomy was placed postnatally. The kidney function improved after the definitive surgery at age 7 months but did not normalize. In contrast, the second child in the CU group had a PUV with a single functioning kidney. Severe AKI was diagnosed on the second day of life, so surgery was promptly performed on the same day. Regarding associated urogenital anomalies, 4/14 children in the PR group had UPJS. The child with the longest operation time in this group (192 min.) underwent a combined procedure of robotic ureter reimplantation and pyeloplasty. Two children in the PR group underwent PR 5 and 2 months after pyeloplasty, respectively. One child was diagnosed with UPJS after the PR surgery. Three children had a single "functioning" kidney. A para-ureteral diverticulum was simultaneously operated on in one child with PR. Other anomalies included VUR I on the contralateral side and cross-right kidney with ectopic right ureter. In the CU group, 3/14 children had UDT, and 2/14 had a single "functioning" kidney. In addition to the above-mentioned child with PUV in this group, two other children were diagnosed with PUV postnatally and were treated with fulguration as neonates. With regard to postoperative complications (< 30 days post-surgery), one child in each group was diagnosed with a UTI, with a positive urine culture. In the further postoperative course, we considered recurrent UTIs in the PR group in the two aforementioned children with persistently postoperative VUR. In the CU group, in addition to the aforementioned child considered a surgical failure, recurrent UTIs were observed in three other children. Two children were definitively treated, and the other child has not yet undergone definitive surgery. In general, the indication for long-term postoperative (after PR or CU) antibiotic treatment was the presence of recurrent UTIs (6/7 children: 2/2 in the PR group and 4/5 in the CU group) or in children with persistent hydroureteronephrosis and pending definitive closure (1/5 in the CU group). By January 2025, definitive therapy had been performed in 11/14 children in the CU group. The average time between the two surgeries was 16.6 months. In one child, a nephrectomy of the affected kidney was performed due to poor function. This child had an initial postnatal partial renal function (PRF) of 16%. After the CU, the kidney did not recover, and the PRF deteriorated to 8%. Surgery is still pending in two children. The average follow-up duration was 33 months in the PR group and 89.5 months in the CU group. This is partly due to some infants in the PR group having a relatively short follow-up period. Furthermore, the infants in the CU group logically require a longer follow-up period due to the staged repair and the time it takes to achieve a definitive repair. Discussion The management of UTD in infants is complex and challenging in pediatric urology [ 9 ]. Compared to treatment protocols for children over the age of one, the optimal therapeutic approach for infants under one year of age is notably more intricate, with limited high-quality evidence guiding clinical decision-making [ 5 ]. Few studies have directly compared postoperative outcomes for infants, and most are retrospective cohort analyses lacking adequate control groups [ 10 ]. Patient population heterogeneity complicates definitive conclusions, as many studies include infants with diverse underlying conditions [ 1 ]. The British Association of Pediatric Urology recommends PR for children older than one year, though this does not apply to infants [ 3 ]. Some studies challenge this by demonstrating favorable outcomes for PR in infants, with one study showing a 97% success rate for infants compared to 86% in older children [ 11 ]. Additionally, no significant difference in bladder function was observed between infants under 12 months and children aged 1–10 years following PR [ 12 ]. In our study, both groups had a success rate of 87%, aligning with studies like Patil et al., who reported 94.4% [ 5 ] and others that showed success rates of 92%-100% for PR in infants [ 10 , 11 , 14 – 17 ]. Our study found a male predominance and left-sided laterality, consistent with other studies [ 5 , 11 ]. Most cases were diagnosed prenatally, with only 6 out of 28 diagnosed after UTI, contrasting with other studies that report higher UTI rates [ 5 , 17 ]. The mean age at surgery was 6.4 months for the PR group and 4 months for the CU group, similar to Patil et al. [ 5 ]. Other studies report PR can be done as early as 1.8-4 months [ 10 , 13 ]. Ureteral tapering during PR was done in 36% of cases in our study, lower than the 65%-77% reported elsewhere [ 5 , 10 ]. Most surgeries were open, with only a few robot-assisted cases. The average operative time for PR was 110.5 minutes, and for CU, it was 64 minutes, similar to Patil et al. [ 5 ]. A meta-analysis found no significant difference between robotic and open PR in success rates or complications, though open PR had shorter operative times but longer hospital stays [ 22 ]. In our study, the average length of stay was 6.4 days for PR and 4.1 days for CU. These figures differ from others, with studies showing shorter stays for younger infants undergoing PR [ 11 , 16 ]. Hydronephrosis severity decreased significantly at the one-year follow-up, consistent with previous studies [ 5 ]. The higher number of unknowns in the PR group may limit direct comparison. The prevalence of associated urogenital malformations in our cohort was higher (50%-57%) compared to other studies, which reported 20.2%-23.3% [ 23 ]. Postoperative complications within 30 days included one UTI in each group (7%), lower than other studies reporting 15% for PR in infants [ 11 ]. Interestingly, while Patil et al. reported a relatively high complication rate of 25% following CU, and Kitchens documented a 31% UTI rate post-CU, our study record only one UTI as a short term CU-related complication [ 5 , 24 ]. Nevertheless, in the CU group, the rate of UTIs and UTI-related hospital admissions was higher. Additionally, the CU requires a certain level of specialized and qualified care. The skin irritations present in the majority of patients in the CU group were not pursued as complications in our clinic due to their mild severity. These are additional factors that speak against CU. Our study is not without limitations. The retrospective nature of our analysis introduces potential biases, including selection bias and variability in surgical decision-making. We could not comment on the postoperative changes in the ureteral diameter following surgical correction since this data was not recorded in all patients, however we have demonstrated in overall improvement of SFU hydronephrosis grade in our patients following successful surgery. The relatively small sample size limits the generalizability of our findings. Additionally, the heterogeneity of our patient population, including mixed etiologies and varied severity of disease, complicates direct comparisons with other studies. Overall, our findings contribute to the growing body of literature on the surgical management of UTD in infants, highlighting comparable success rates between PR and CU while also shedding light on differences in complication rates, hospital stay duration, and associated anomalies. As evidence continues to evolve, future studies incorporating larger, well-controlled patient cohorts will be essential in refining treatment guidelines and optimizing surgical outcomes for this vulnerable population. In Conclusion, PR in infants is a safe and effective treatment option, comparable to CU. As a single-stage procedure, PR eliminates the need for additional surgeries, reducing the overall treatment burden on patients. Additionally, it helps prevent complications associated with urostomies. The increasing adoption of robotic-assisted PR has further improved outcomes, allowing for quicker postoperative recovery and shorter hospital stays, making it a viable and efficient approach for managing urinary tract dilation in infants. Declarations Declaration of interest : None. Funding: We state that we have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. Moayad Beibooh: Conception, design, acquisition of data, analysis of data, draft the manuscript. Jawdat Jaber: Conception, design, manuscript revision. Galiya Raisin: Design, manuscript revision. Boris Chertin: Conception, design, analysis of data, manuscript revision. Stanislav Kocherov: Conception, design, manuscript revision. Leon Chertin: Conception, design, analysis of data, draft the manuscript, English copy editing. Author Contribution Moayad Beibooh: Conception, design, acquisition of data, analysis of data, draft the manuscript. Jawdat Jaber: Conception, design, manuscript revision. Galiya Raisin: Design, manuscript revision. Boris Chertin: Conception, design, analysis of data, manuscript revision.Stanislav Kocherov: Conception, design, manuscript revision.Leon Chertin: Conception, design, analysis of data, draft the manuscript, English copy editing References Nguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, Coleman B et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol 10:982–998. https://doi.org/10.1016/j.jpurol.2014.10.002 Tekgul S, Riedmiller H, Hoebeke P, Kocvara R, Nijman RJ, Radmayr C et al (2012) EAU guidelines on vesicoureteral reflux in children. Eur Urol 62:534–542. https://doi.org/10.1016/j.eururo.2012.05.059 Farrugia MK, Hitchcock R, Radford A, Burki T, Robb A, Murphy F et al (2014) British Association of Paediatric Urologists consensus statement on the management of the primary obstructive megaureter. 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Supplementary Files Table1ureteralreimplantation.docx Table2ureteralreimplantation.docx Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2025 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Revision requested 02 Oct, 2025 Reviews received at journal 17 Sep, 2025 Reviewers agreed at journal 10 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 08 Sep, 2025 Editor assigned by journal 04 Sep, 2025 Submission checks completed at journal 04 Sep, 2025 First submitted to journal 30 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7495005","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":513144432,"identity":"6b2158f2-4438-47c8-8346-673a26845ac7","order_by":0,"name":"Moayad Beibooh","email":"","orcid":"","institution":"Shaare Zedek Medical Center, The Hebrew University","correspondingAuthor":false,"prefix":"","firstName":"Moayad","middleName":"","lastName":"Beibooh","suffix":""},{"id":513144433,"identity":"54c98f06-4bb0-48bd-ba2e-b91bd1b7fd8b","order_by":1,"name":"Jawdat Jaber","email":"","orcid":"","institution":"Shaare Zedek Medical Center, The Hebrew University","correspondingAuthor":false,"prefix":"","firstName":"Jawdat","middleName":"","lastName":"Jaber","suffix":""},{"id":513144434,"identity":"b0dc9655-599e-400f-aa11-54dfa7fc40d9","order_by":2,"name":"Galiya Raisin","email":"","orcid":"","institution":"Shaare Zedek Medical Center, The Hebrew University","correspondingAuthor":false,"prefix":"","firstName":"Galiya","middleName":"","lastName":"Raisin","suffix":""},{"id":513144435,"identity":"b7b4390d-df91-4372-b399-f7ca981a6fca","order_by":3,"name":"Boris Chertin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBACAyA+AMQJDGBGBZBkZm4gVgszkHEGpIWRsBYGmBYGxjYQm4AWc/behwd/MNjl8UufP3i4cF5tNH87UMuPim04tVj2HDc4zMOQXCzZl8xweOa247kzDjM2MPacuY3bYTfSGA4DvZO44Qwzw2HebcdyG4BamBnb8GsBOuxA4n6wljnHcucTo+UAD8gWHpCWhprcDYS0WPYcYzjMY5CcOOMMM9BTxw7kbgRqOYjPL+bsbcwff1TYJfb3MD7+zFNTlzvv/OGDD35U4NYCdR6cdRhMHiCgHgXUkaJ4FIyCUTAKRggAAJShXKUEIqqSAAAAAElFTkSuQmCC","orcid":"","institution":"Shaare Zedek Medical Center, The Hebrew University","correspondingAuthor":true,"prefix":"","firstName":"Boris","middleName":"","lastName":"Chertin","suffix":""},{"id":513144436,"identity":"2594a1eb-7cf6-4d5f-98d1-383373d462e7","order_by":4,"name":"Stanislav Kocherov","email":"","orcid":"","institution":"Shamir Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Stanislav","middleName":"","lastName":"Kocherov","suffix":""},{"id":513144437,"identity":"1e1fea43-4133-4530-a415-e26da82fc6ac","order_by":5,"name":"Leon Chertin","email":"","orcid":"","institution":"Shamir Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Leon","middleName":"","lastName":"Chertin","suffix":""}],"badges":[],"createdAt":"2025-08-30 11:38:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7495005/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7495005/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-025-06220-6","type":"published","date":"2025-10-16T15:58:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":93956057,"identity":"fd0bbb9d-cc57-41a7-8c5d-185dab5a8b8a","added_by":"auto","created_at":"2025-10-20 16:09:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":544190,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7495005/v1/e4fdce7a-cf93-45f0-b52b-b0ff4f9ed314.pdf"},{"id":91311824,"identity":"9b70fcc3-97a7-423b-b386-fa6629aef96f","added_by":"auto","created_at":"2025-09-15 07:33:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23650,"visible":true,"origin":"","legend":"","description":"","filename":"Table1ureteralreimplantation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7495005/v1/78e9547dc08cd57a45c8b5be.docx"},{"id":91314172,"identity":"a83b1433-c3d0-4403-bd08-644a5692a5e1","added_by":"auto","created_at":"2025-09-15 07:57:22","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28585,"visible":true,"origin":"","legend":"","description":"","filename":"Table2ureteralreimplantation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7495005/v1/4a2ed1c0f5c8633b8885b91e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Outcomes of Primary Ureteral Reimplantation Versus Staged Cutaneous Ureterostomy in Infants Under One with Primary Obstructive Megaureters and Vesicoureteral Reflux: A Multi-Center Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrinary tract dilatation (UTD) is the second most frequently diagnosed prenatal anomaly, affecting approximately 1\u0026ndash;2% of fetuses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The causes of UTD vary, with a transient form occurring in 50\u0026ndash;70% of cases and resolving spontaneously over time. Among the known etiologies, ureteropelvic junction obstruction (UPJO) is the most common cause of antenatal UTD, followed by vesicoureteral reflux (VUR) in 10\u0026ndash;40% of cases, and ureterovesical junction obstruction (UVJO) in 5\u0026ndash;15% of cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Obstructive megaureter is defined as a ureter diameter exceeding 7 mm. For children with grade III\u0026ndash;V VUR, the European Association of Urology (EAU) guidelines recommend initial antibiotic prophylaxis. However, for those with high-grade VUR, surgical options such as ureteral reimplantation should be considered [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In symptomatic patients, clinical signs such as pain, recurrent urinary tract infections (UTIs) despite antibiotic prophylaxis, or worsening UTD, along with a differential renal function below 40% or a progressive decline on serial renograms, may indicate the need for surgical intervention [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A range of treatment options are available, with the choice influenced by the child\u0026rsquo;s overall health, age, presence of other malformations, and the severity of the condition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Depending on VUR severity, minimally invasive procedures like endoscopic correction can be considered. We have previously described our experience in the treatment of more than 1300 reimplantations due to VUR and primary obstructive megaureter (POM) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In cases requiring surgery during infancy, the approach may involve primary ureteral reimplantation (PR) or a staged procedure, which includes an initial cutaneous ureterostomy (CU) followed by delayed reimplantation. The rationale for the two-stage procedure is to reduce the complexity and duration of the first surgery in infancy. The British Association of Pediatric Urologists suggests deferring definitive repair until the child reaches one year of age, using temporizing interventions in the meantime [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this recommendation lacks strong supporting evidence and exposes the child to additional procedures. CU is associated with risks such as stomal stenosis (8\u0026ndash;22%), febrile UTIs (31%), and pyelonephritis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Few studies have directly compared the safety, efficacy, and long-term outcomes of primary definitive repair versus a staged approach in infants under 12 months with POM [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this multicenter study, we aim to evaluate the management and long-term outcomes of pediatric patients under one year of age with POM and VUR who underwent either PR or a two-stage procedure (CU followed by reimplantation). Our hypothesis is that PR is a safe and effective treatment in infancy compared to the staged approach.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This multi-institutional study includes all pediatric patients under 12 months who underwent either PR or CU for POM or VUR between 1994 and 2024 across two medical centers, with ethical approval from the respective institutional review boards of both centers. Perioperative and follow-up data were meticulously collected and are presented in Table\u0026nbsp;1. Perioperative and follow-up data were meticulously collected for each patient. The preoperative assessment included a comprehensive history, physical examination, urinalysis, urine culture, renal ultrasound (US), radionuclide diuretic renal scan (MAG3), and voiding cystourethrography (VCUG). Surgical indications for the POM group were based on the British Association of Pediatric Urologists (BAPU) consensus guidelines and included recurrent UTIs, impaired renal function (with a relative function of less than 40% on MAG3 scans), deterioration of function (greater than 10% worsening on consecutive MAG3 scans), or progressive hydronephrosis and/or hydroureter [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For the VUR group, indications for surgery included recurrent febrile UTIs despite prophylactic antibiotics, or evidence of obstructive refluxing megaureter supported by existence of beak sign on the VCUG images accompanied by deterioration of the renal function or break through infections while on antibiotic prophylaxis.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgical Techniques for Ureteral Reimplantation\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eOpen Ureteral Reimplantation\u003c/h2\u003e\u003cp\u003eThe LEADBETTER-POLITANO method was utilized in our institutions. The affected ureter is mobilized and electrically dissected intravesically. A submucosal tunnel is created, and the ureter is fixed to the bladder muscle after slight shortening.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eRobotic-Assisted Laparoscopic Ureteral Reimplantation (RALUR)\u003c/h3\u003e\n\u003cp\u003eUsing the Da Vinci Xi platform, a transperitoneal approach is employed, following the Lich-Gregoir method [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The patient is positioned supine, and general anesthesia is induced, often with caudal or quadratus lumborum blocks [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The procedure begins with trocar placement (8-mm camera port, two 8-mm working ports), The distal ureter is dissected to the UVJ with particular attention to avoiding damage to pelvic nerve branches. Once the tunnel is created, the ureter is placed into the detrusor muscle, and the tunnel is sutured over it. Special care is taken to avoid injury to the vas deferens. No external drains or prophylactic antibiotics are used postoperatively.\u003c/p\u003e\n\u003ch3\u003eRobotic-Assisted Dismembered Extravesical Cross-Trigonal Ureteral Reimplantation (RADECUR)\u003c/h3\u003e\n\u003cp\u003eThis technique is used for complex cases as we previously described. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A transverse detrusorrhaphy is performed on the ipsilateral side of the contralateral ureter. The ureter is tailored when needed, and a bladder-ureter anastomosis is created using Maxon 4\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures over a double-J stent. Detrusorrhaphy is closed with a running V-Lock suture.\u003c/p\u003e\n\u003ch3\u003eDelayed Staged Repair (DSR)\u003c/h3\u003e\n\u003cp\u003eInfants undergo CU to drain the obstructed system. Extraperitoneal exposure is achieved via a modified Gibson incision. After transecting the ureter, a lateral ureteral stoma is created, which is left intubated during the early postoperative course. After a year, a definitive repair with intravesical reimplantation is performed. The urethral catheter is removed on day 1. In those children who required bilateral CU bladder cycling program was initiated following procedure in order to avoid dry bladder and allow normal bladder capacity development and continued till definitive treatment.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eCategorical data were analyzed using the Fisher exact or chi-square test, with significance at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistical evaluations were conducted using GraphPad Prism version 6.01.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-eight children with UTD of varying etiology were included in our study. Fourteen underwent PR, and fourteen underwent CU as part of a two-stage approach. Operative and postoperative data are presented in Table\u0026nbsp;2. Preoperative both groups had a high proportion of severe hydronephrosis, as classified by the Society for Fetal Urology (SFU) grading system, with the CU group having slightly more severe cases 9 SFU IV und 4 SFU III vs. 7 SFU IV und 3 SFU III in the PR group. At 1-Year Follow-Up both groups showed improvement, with many patients downgraded to SFU I or II. Also, both groups had patients with normal US findings postoperatively (1 in the PR group and 2 in the CU group).\u003c/p\u003e\u003cp\u003eAfter PR, we observed a significant reduction in SFU grade in our patient cohort at the 1-year follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Two children developed recurrent UTIs due to underlying persistent VUR despite prophylactic antibiotics, requiring two additional surgeries in the form of endoscopic VUR correction. Similarly, after CU, we observed a significant reduction in SFU grade at 1-year follow-up (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In two children, moderate-severe hydronephrosis was still detectable postoperatively. One child with recurrent UTIs despite prophylactic antibiotic treatment was found to have an additional UVJ stenosis on the contralateral side and underwent bilateral open ureter reimplantation at the age of 3. The second child developed two episodes of idiopathic urinary retention. Subsequently, an open ureteral reimplantation was performed due to de novo VUR on the contralateral side. When comparing the SFU grades between the two groups, no statistically significant difference was found both preoperatively and at 1 year postoperatively. In the PR group, ureteral tapering was performed in 5/14 cases, compared to none in the comparison group. Ureteral diameter was documented only in isolated cases, so we decided not to conduct further analysis on this parameter. Surgery in the PR group was performed at a mean age of 6.9 months, compared to 4 months in the CU group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Regarding the duration of operation, the procedure in the PR group took an average of 110.5 minutes, compared to 64 minutes in the CU group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, there was a statistically significant difference in the mean hospital stay, with 6.4 days in the PR group versus 4.1 days in the CU group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). A postnatal impaired kidney function (abnormal creatinine, GFR was not routinely estimated) was observed in two children in each group. In the case of one child in each group, the kidney function normalized after hydration, allowing the surgery to be delayed and performed electively. The second child in the PR group had a single kidney with POM and UPJS. Initially, a nephrostomy was placed postnatally. The kidney function improved after the definitive surgery at age 7 months but did not normalize. In contrast, the second child in the CU group had a PUV with a single functioning kidney. Severe AKI was diagnosed on the second day of life, so surgery was promptly performed on the same day. Regarding associated urogenital anomalies, 4/14 children in the PR group had UPJS. The child with the longest operation time in this group (192 min.) underwent a combined procedure of robotic ureter reimplantation and pyeloplasty. Two children in the PR group underwent PR 5 and 2 months after pyeloplasty, respectively. One child was diagnosed with UPJS after the PR surgery. Three children had a single \"functioning\" kidney. A para-ureteral diverticulum was simultaneously operated on in one child with PR. Other anomalies included VUR I on the contralateral side and cross-right kidney with ectopic right ureter. In the CU group, 3/14 children had UDT, and 2/14 had a single \"functioning\" kidney. In addition to the above-mentioned child with PUV in this group, two other children were diagnosed with PUV postnatally and were treated with fulguration as neonates. With regard to postoperative complications (\u0026lt;\u0026thinsp;30 days post-surgery), one child in each group was diagnosed with a UTI, with a positive urine culture. In the further postoperative course, we considered recurrent UTIs in the PR group in the two aforementioned children with persistently postoperative VUR. In the CU group, in addition to the aforementioned child considered a surgical failure, recurrent UTIs were observed in three other children. Two children were definitively treated, and the other child has not yet undergone definitive surgery. In general, the indication for long-term postoperative (after PR or CU) antibiotic treatment was the presence of recurrent UTIs (6/7 children: 2/2 in the PR group and 4/5 in the CU group) or in children with persistent hydroureteronephrosis and pending definitive closure (1/5 in the CU group). By January 2025, definitive therapy had been performed in 11/14 children in the CU group. The average time between the two surgeries was 16.6 months. In one child, a nephrectomy of the affected kidney was performed due to poor function. This child had an initial postnatal partial renal function (PRF) of 16%. After the CU, the kidney did not recover, and the PRF deteriorated to 8%. Surgery is still pending in two children.\u003c/p\u003e\u003cp\u003eThe average follow-up duration was 33 months in the PR group and 89.5 months in the CU group. This is partly due to some infants in the PR group having a relatively short follow-up period. Furthermore, the infants in the CU group logically require a longer follow-up period due to the staged repair and the time it takes to achieve a definitive repair.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe management of UTD in infants is complex and challenging in pediatric urology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Compared to treatment protocols for children over the age of one, the optimal therapeutic approach for infants under one year of age is notably more intricate, with limited high-quality evidence guiding clinical decision-making [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Few studies have directly compared postoperative outcomes for infants, and most are retrospective cohort analyses lacking adequate control groups [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Patient population heterogeneity complicates definitive conclusions, as many studies include infants with diverse underlying conditions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The British Association of Pediatric Urology recommends PR for children older than one year, though this does not apply to infants [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Some studies challenge this by demonstrating favorable outcomes for PR in infants, with one study showing a 97% success rate for infants compared to 86% in older children [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, no significant difference in bladder function was observed between infants under 12 months and children aged 1\u0026ndash;10 years following PR [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, both groups had a success rate of 87%, aligning with studies like Patil et al., who reported 94.4% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and others that showed success rates of 92%-100% for PR in infants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Our study found a male predominance and left-sided laterality, consistent with other studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Most cases were diagnosed prenatally, with only 6 out of 28 diagnosed after UTI, contrasting with other studies that report higher UTI rates [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The mean age at surgery was 6.4 months for the PR group and 4 months for the CU group, similar to Patil et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Other studies report PR can be done as early as 1.8-4 months [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Ureteral tapering during PR was done in 36% of cases in our study, lower than the 65%-77% reported elsewhere [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Most surgeries were open, with only a few robot-assisted cases. The average operative time for PR was 110.5 minutes, and for CU, it was 64 minutes, similar to Patil et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A meta-analysis found no significant difference between robotic and open PR in success rates or complications, though open PR had shorter operative times but longer hospital stays [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study, the average length of stay was 6.4 days for PR and 4.1 days for CU. These figures differ from others, with studies showing shorter stays for younger infants undergoing PR [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Hydronephrosis severity decreased significantly at the one-year follow-up, consistent with previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The higher number of unknowns in the PR group may limit direct comparison. The prevalence of associated urogenital malformations in our cohort was higher (50%-57%) compared to other studies, which reported 20.2%-23.3% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Postoperative complications within 30 days included one UTI in each group (7%), lower than other studies reporting 15% for PR in infants [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Interestingly, while Patil et al. reported a relatively high complication rate of 25% following CU, and Kitchens documented a 31% UTI rate post-CU, our study record only one UTI as a short term CU-related complication [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Nevertheless, in the CU group, the rate of UTIs and UTI-related hospital admissions was higher. Additionally, the CU requires a certain level of specialized and qualified care. The skin irritations present in the majority of patients in the CU group were not pursued as complications in our clinic due to their mild severity. These are additional factors that speak against CU.\u003c/p\u003e\u003cp\u003eOur study is not without limitations. The retrospective nature of our analysis introduces potential biases, including selection bias and variability in surgical decision-making. We could not comment on the postoperative changes in the ureteral diameter following surgical correction since this data was not recorded in all patients, however we have demonstrated in overall improvement of SFU hydronephrosis grade in our patients following successful surgery. The relatively small sample size limits the generalizability of our findings. Additionally, the heterogeneity of our patient population, including mixed etiologies and varied severity of disease, complicates direct comparisons with other studies. Overall, our findings contribute to the growing body of literature on the surgical management of UTD in infants, highlighting comparable success rates between PR and CU while also shedding light on differences in complication rates, hospital stay duration, and associated anomalies. As evidence continues to evolve, future studies incorporating larger, well-controlled patient cohorts will be essential in refining treatment guidelines and optimizing surgical outcomes for this vulnerable population.\u003c/p\u003e\u003cp\u003eIn Conclusion, PR in infants is a safe and effective treatment option, comparable to CU. As a single-stage procedure, PR eliminates the need for additional surgeries, reducing the overall treatment burden on patients. Additionally, it helps prevent complications associated with urostomies. The increasing adoption of robotic-assisted PR has further improved outcomes, allowing for quicker postoperative recovery and shorter hospital stays, making it a viable and efficient approach for managing urinary tract dilation in infants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of interest\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe state that we have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.\u003c/p\u003e\n\u003cp\u003eMoayad Beibooh: Conception, design, acquisition of data, analysis of data, draft the manuscript.\u003c/p\u003e\n\u003cp\u003eJawdat Jaber: Conception, design, manuscript revision.\u003c/p\u003e\n\u003cp\u003eGaliya Raisin: Design, manuscript revision.\u003c/p\u003e\n\u003cp\u003eBoris Chertin: Conception, design, analysis of data, manuscript revision.\u003c/p\u003e\n\u003cp\u003eStanislav Kocherov: Conception, design, manuscript revision.\u003c/p\u003e\n\u003cp\u003eLeon Chertin: Conception, design, analysis of data, draft the manuscript, English copy editing.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eMoayad Beibooh: Conception, design, acquisition of data, analysis of data, draft the manuscript. Jawdat Jaber: Conception, design, manuscript revision. Galiya Raisin: Design, manuscript revision. Boris Chertin: Conception, design, analysis of data, manuscript revision.Stanislav Kocherov: Conception, design, manuscript revision.Leon Chertin: Conception, design, analysis of data, draft the manuscript, English copy editing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNguyen HT, Benson CB, Bromley B, Campbell JB, Chow J, Coleman B et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system). J Pediatr Urol 10:982\u0026ndash;998. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpurol.2014.10.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jpurol.2014.10.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTekgul S, Riedmiller H, Hoebeke P, Kocvara R, Nijman RJ, Radmayr C et al (2012) EAU guidelines on vesicoureteral reflux in children. 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Nihon Hinyokika Gakkai Zasshi 87:909\u0026ndash;914. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5980/jpnjurol1989.87.909\u003c/span\u003e\u003cspan address=\"10.5980/jpnjurol1989.87.909\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSforza S, Marco BB, Haid B, Baydilli N, Donmez MI, Spinoit AF et al (2024) A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV-V) vesicoureteral reflux. J Pediatr Urol 20:283\u0026ndash;291. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpurol.2023.11.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jpurol.2023.11.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang X, Tao T, Li P, Zhao Y, Cao H, Tao Y et al (2025) Comparison of Robot-assisted Laparoscopic Extravesical Ureteral Reimplantation for Primary Vesicoureteral Reflux in Infants Under One Year of Age and Older Children. 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J Pediatr Urol 15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpurol.2018.09.011\u003c/span\u003e\u003cspan address=\"10.1016/j.jpurol.2018.09.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 66 e1- e5\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu C, Chin T, Wei C (1998) Surgical treatment of vesicoureteral reflux in infants under 3 months of age. J Pediatr Surg 33:1716\u0026ndash;1719. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0022-3468(98)90617-0\u003c/span\u003e\u003cspan address=\"10.1016/s0022-3468(98)90617-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShrestha AL, Bal HS, Kisku SMC, Sen S (2018) Outcome of end cutaneous ureterostomy (ECU) as a non conservative option in the management of primary obstructive megaureters (POM). J Pediatr Urol 14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jpurol.2018.05.004\u003c/span\u003e\u003cspan address=\"10.1016/j.jpurol.2018.05.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 541 e1- e5\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeng T, Liu B, Luo L, Duan X, Cai C, Zhao Z et al (2018) Robot-assisted laparoscopic versus open ureteral reimplantation for pediatric vesicoureteral reflux: a systematic review and meta-analysis. World J Urol 36:819\u0026ndash;828. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00345-018-2194-x\u003c/span\u003e\u003cspan address=\"10.1007/s00345-018-2194-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNascimben F, Molinaro F, Maffi M, Nino F, Lachkar A, Zislin M et al (2024) Endoscopic injection vs anti-reflux surgery for moderate- and high-grade vesicoureteral reflux in children: a cost-effectiveness international study. J Robot Surg 18:371. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-024-02103-5\u003c/span\u003e\u003cspan address=\"10.1007/s11701-024-02103-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKitchens DM, DeFoor W, Minevich E, Reddy P, Polsky E, McGregor A et al (2007) End cutaneous ureterostomy for the management of severe hydronephrosis. J Urol 177:1501\u0026ndash;1504. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.juro.2006.11.076\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2006.11.076\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\n\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Antenatal urinary tract dilatation, primary obstructive megaureter, vesicoureteral reflux, ureteral reimplantation, cutaneous ureterostomy, pediatric urology","lastPublishedDoi":"10.21203/rs.3.rs-7495005/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7495005/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e This study evaluates the management and long-term outcomes of pediatric patients under one year of age with primary obstructive megaureters (POM) and vesicoureteral reflux (VUR), comparing primary ureteral reimplantation (PR) to a two-stage approach involving cutaneous ureterostomy (CU) followed by reimplantation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A multi-institutional study was conducted between 1994 and 2024, including 28 pediatric patients under 12 months of age. Participants were divided into two groups: PR (n=14) and CU (n=14). Comprehensive preoperative assessments, including renal ultrasound, voiding cystourethrography, and radionuclide diuretic renal scans, were performed. Surgical indications were based on recurrent UTIs, impaired renal function, or progressive hydronephrosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNo significant difference in hydroureteronephrosis grade (SFU) was observed between the two groups (p \u0026lt; 0.05). In the PR group, two children required additional surgeries due to recurrent UTIs. Similarly, in the CU group, two children underwent subsequent ureteral reimplantation. The mean age at primary surgery was 6.9 months for the PR group, compared to 4 months for ureterostomy in the CU group (p \u0026lt; 0.05). The average operation time was 110.5 minutes for PR, versus 64 minutes for CU (p \u0026lt; 0.05). Overall, more complications occurred in the group of children with CU until a definitive repair was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Both primary ureteral reimplantation and the two-stage approach with cutaneous ureterostomy followed by reimplantation demonstrated effective outcomes in managing POM and VUR in infants. Given the findings, primary ureteral reimplantation may be considered a safe and effective approach in infants under one year old with these conditions.\u003c/p\u003e","manuscriptTitle":"Comparative Outcomes of Primary Ureteral Reimplantation Versus Staged Cutaneous Ureterostomy in Infants Under One with Primary Obstructive Megaureters and Vesicoureteral Reflux: A Multi-Center Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 07:33:17","doi":"10.21203/rs.3.rs-7495005/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-02T12:19:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T19:14:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167442495187548432068350869429836070329","date":"2025-09-10T13:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103181004782665440175536069236498854908","date":"2025-09-08T10:19:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T09:24:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-04T16:52:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T15:26:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2025-08-30T11:22:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b630cd6c-4bbe-4d9f-899b-23127e105318","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:03:58+00:00","versionOfRecord":{"articleIdentity":"rs-7495005","link":"https://doi.org/10.1007/s00383-025-06220-6","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2025-10-16 15:58:20","publishedOnDateReadable":"October 16th, 2025"},"versionCreatedAt":"2025-09-15 07:33:17","video":"","vorDoi":"10.1007/s00383-025-06220-6","vorDoiUrl":"https://doi.org/10.1007/s00383-025-06220-6","workflowStages":[]},"version":"v1","identity":"rs-7495005","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7495005","identity":"rs-7495005","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}