A Comparative Study on the Efficacy of Laparoscopic Ureteroureterostomy versus Single Ureteral Bladder Reimplantation in Treating Pediatric Complete Renal Duplication

A Comparative Study on the Efficacy of Laparoscopic Ureteroureterostomy versus Single Ureteral Bladder Reimplantation in Treating Pediatric Complete Renal Duplication | 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 A Comparative Study on the Efficacy of Laparoscopic Ureteroureterostomy versus Single Ureteral Bladder Reimplantation in Treating Pediatric Complete Renal Duplication bin yu, yingzhong fan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4932918/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Nov, 2024 Read the published version in Pediatric Surgery International → Version 1 posted 7 You are reading this latest preprint version Abstract Objective: To explore the therapeutic value of laparoscopic ureteroureterostomy compared to single ureteral bladder reimplantation in the treatment of pediatric complete renal duplication. Methods: This retrospective study included 80 pediatric patients with complete renal duplication who underwent surgical treatment at the First Affiliated Hospital of Zhengzhou University from January 2015 to December 2022. Patients were divided into two groups based on the surgical approach: the laparoscopic ureteroureterostomy group (LUU group, n=45) and the single ureteral bladder reimplantation group (UR group, n=35). The two groups were compared in terms of operative time, intraoperative blood loss, number of stent placements, postoperative length of hospital stay, changes in ante-posterior diameter (APD) of the affected upper kidney pelvis before and after surgery, changes in upper ureteral diameter (UD), and variations in renal function. Results: The LUU group demonstrated significantly shorter operative time (t=3.480, P=0.004), less intraoperative blood loss (t=-2.465, P=0.0196), and reduced postoperative length of stay (t=2.308, P=0.027) compared to the UR group. There was no significant difference between the two groups regarding the number of stent placements (x²=0.762, P=0.383). The UR group had four cases of long-term complications (two cases of anastomotic stricture, one case of vesicoureteral reflux, and one case of recurrent urinary tract infection), while the LUU group experienced one case of long-term complication (one case of anastomotic stricture), with no significant difference between groups (x²=1.493, P=0.222). Both groups showed significant improvement in preoperative and postoperative APD, UD, and affected side differential renal function (DRF). However, the differences in improvement values for upper kidney pelvis APD (ΔAPD; t=-0.032, P=0.962), differential renal function (ΔDRF; Z=1.895, P=0.073), and ureteral diameter (ΔUD; t=1.832, P=0.079) were not statistically significant. Conclusion: Both LUU and UR procedures are safe and effective in treating pediatric complete renal duplication. Compared to UR, LUU results in shorter operative time, less intraoperative blood loss, and reduced postoperative length of stay, while also causing less damage to the bladder. Laparoscopy Ureteroureterostomy Ureteral Reimplantation Duplex kidney Pediatric Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Renal-ureteral duplication malformation is the most common renal anomaly in children[1], with an incidence reported at approximately 0.8%[2]. It is more frequently observed in females than in males[3], and unilateral cases are more common than bilateral ones, with no significant difference in the incidence between the left and right sides. Additionally, children with duplicated kidneys often present with associated ureteral anomalies, such as ureteral terminal dilatation and ectopic ureteral openings. Given the complex and diverse complications associated with duplicated kidneys, there is currently no unified standard for the diagnosis and treatment of this condition; management often requires a comprehensive assessment based on differential renal function and concomitant ureteral abnormalities[4]. The primary treatment options for preserving the upper pole of the kidney in cases of renal duplication include: ① transurethral endoscopic ureteral resection; ②Ureteroureterostomy; ③ lower urinary tract reconstruction. In cases where the upper pole kidney has poor or non-functional capabilities, partial nephrectomy may also be considered[5, 6]. This study aims to investigate the safety and efficacy of laparoscopic Ureteroureterostomy (LUU) and single ureteral bladder reimplantation (UR) in treating pediatric patients with complete renal-ureteral duplication malformation, providing clinical evidence for the rational selection of surgical methods. Materials and Methods Clinical Data We collected clinical data from 80 pediatric patients diagnosed with complete renal-ureteral duplication malformation at the First Affiliated Hospital of Zhengzhou University between January 2016 and December 2022. Preoperative diagnosis was confirmed through imaging studies, including urinary system ultrasound, diuretic renal scintigraphy, CT urogram (CTU), voiding cystourethrogram (VCUG), and magnetic resonance urography (MRU). All cases were unilateral. Patients were categorized based on surgical approach into the laparoscopic ureteroureterostomy group (LUU group, n=45) and the single ureteral reimplantation group (UR group, n=35). Detailed preoperative clinical data for both groups are summarized in Tables 1. Inclusion criteria were as follows: ① definitive preoperative diagnosis of complete renal-ureteral duplication malformation with concomitant ipsilateral ectopic ureteral openings or ureteral dilatation; exclusion of cases with simultaneous lesions in both ureters on the same side; ② progressive worsening of hydronephrosis due to duplicated kidneys; ③ presence of recurrent urinary tract infections, urinary incontinence during intervals, flank or abdominal pain. Exclusion criteria included: ① distal “Y”-type ureteral duplication malformation; ② findings of renal developmental dysplasia or poor function in the upper pole as indicated by diuretic renal scintigraphy or CTU; ③ acute phase of urinary tract infection or affected kidney diagnosed as pyonephrosis. The differential renal function (DRF) values were calculated considering the affected side's upper and lower poles together before and after surgery. Follow-up evaluations included urinary system ultrasound at 1, 3, and 12 months postoperatively; diuretic renal scintigraphy and CTU at 6 months postoperative. For children undergoing ureteral bladder reimplantation who did not present urinary tract infection symptoms postoperatively, routine follow-up VCUG was not scheduled. This study received formal approval from the Institutional Review Board of the First Affiliated Hospital of Zhengzhou University (Approval No: 2023-KY-0573), and all families of participating patients were fully informed about the study's content and provided written informed consent. Table1 Clinical profiles of 80 children with complete duplicated collecting systems LUU UR P Value Number of cases 45 35 Age, months 12.85（2,85） 13.76（3,83） 0.63 Gender(M/F) 29/16 22/13 0.48 Laterality（L/R) 24/21 19/16 0.72 Diagnosis, case ureteral ectopia 25 17 ureterocele 13 15 Obstructed ureter 7 3 Uti, case 15 12 APD,mm 16.4±10.2 18.5±8.6 0.201 UD, mm 9.5±5.2 10.7±5.4 0.255 DRF, % 43.65±4.48 42.59±6.54 0.503 Abbreviations and Acronyms: LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function Surgical Methods All pediatric patients with urinary tract infections underwent surgical treatment after controlling the infection with antibiotics. In the LUU group: general anesthesia was induced using a combination of intravenous and inhalational agents. Following the induction of anesthesia, patients were positioned in a lithotomy position, and cystoscopy was performed to assess the smoothness of the bladder mucosa and the location of the ureteral openings. If the recipient ureter was found to be relatively narrow, a stent was placed into the recipient ureter via the cystoscope. The position was then changed to a head-down tilt, and three 5 mm trocars were inserted at the subumbilical level laterally to the rectus abdominis muscles to establish pneumoperitoneum. Using the stent as a guide, the anatomical relationship between the upper and lower ureters was clarified at the pelvic inlet. An electric hook was utilized to open the posterior peritoneum at the intersection of the ureter and iliac vessels, and the tortuous dilated ureter was freed from surrounding tissue until it was tension-free. The dilated ureter was ligated across at the point anterior to the iliac vessels, and a longitudinal incisional cut was made on the lateral wall of the lower ureter, with the incision length matched to the diameter of the diseased segment of the ureter. Through the pre-placed stent, the anatomical relationship between the upper and lower ureters was re-confirmed. The donor ureter was anastomosed to the recipient ureter using 5-0 absorbable sutures in a tension-free, non-tortuous manner to form a Y-shaped ureter. If the upper ureter had a diameter ≥ 1.5cm, non-tortuous manner to form a Y-shaped ureter. If the upper ureter had a diameter ≥ 1.5cm, the ureter would be trimmed prior to anastomosis. The residual ureteral stump was meticulously mobilized and expanded to the junction of the ureter and bladder or to the common sheath if both ureters were present, and this was secured with sutures. Finally, the pelvic peritoneum was closed and repaired. In the UR group: Following the induction of anesthesia, patients were positioned supine with a urinary catheter left in place. Three 5 mm trocars were inserted at the subumbilical level laterally to the rectus abdominis muscles to establish pneumoperitoneum. The posterior peritoneum above the bladder was opened, and the tortuous dilated ureter was freed until reaching the junction of the ureter and bladder or the common sheath of both ureters. The bladder's posterior lateral muscle layer was incised along the natural course of the ureter, exposing the bladder mucosa. Physiological saline was injected through the catheter to distend the bladder mucosa, and the bladder muscle layer was dissected laterally to ensure that the length of the submucosal tunnel was 4 to 5 times the diameter of the reimplanted ureter, with a width twice that size. The upper ureter was ligated at the bladder entrance and subsequently transected. The distal end of the ureter was trimmed to achieve an opening diameter of 4 to 6 mm. An incision was made at the proximal end of the original bladder entrance, and the Lich-Gregoir[7] method was employed for the burying suture technique, followed by interrupted sutures to close the bladder muscle layer. For patients with significant ureteral ballooning (a total of 13 cases in this group), electrocautery was performed around the protrusion using a cystoscope before proceeding with reimplantation according to the Cohen[8] technique. If the diameter of the upper ureter reached or exceeded 1.5 cm, it was first trimmed to reduce the diameter to between 6 and 8 mm, after which a stent was placed percutaneously, followed by ureter reconstruction (UR) surgery. In the UR group, a total of 20 patients underwent ureteral trimming and reconstruction. Stented ureters placed during the operation were removed via cystoscopy 6 to 8 weeks postoperatively. Data Collection Data were meticulously recorded and compared between the LUU group and UR group regarding surgical-related metrics. This included operation time, intraoperative blood loss, postoperative complications, length of hospital stay, as well as postoperative measurements such as the anteroposterior renal pelvic diameter (APD) of the affected upper kidney, ureter diameter (UD), and differential renal function (DRF) of the affected side. Statistical Methods Data analysis for this study was conducted using SPSS29.0 statistical software. Continuous variables that followed a normal distribution were presented as means ± standard deviations (X̅ ± S), with inter-group differences assessed using independent samples t-tests and intra-group differences analyzed through paired t-test. For continuous variables not conforming to a normal distribution, medians (M) and interquartile ranges (Q1, Q3) were utilized for description, with rank-sum tests employed to compare mean differences between the two groups. Additionally, gender and side were treated as categorical variables, and comparisons of rates between two samples were performed using chi-square tests (X² test). P<0.05 was considered statistically significant. Results The LUU group demonstrated significantly shorter operation times (t=3.480, P=0.004), reduced intraoperative blood loss (t=-2.465, P=0.0196), and fewer postoperative hospital days (t=2.308, P=0.027) compared to the UR group, with all differences being statistically significant (Tables 2 and 3). The number of stent placements in the LUU group compared to the UR group showed no statistically significant difference (χ²=0.762, P=0.383). In the UR group, there were four cases of long-term complications (two cases of anastomotic stricture, one case of vesicoureteral reflux, and one case of recurrent urinary tract infection), while the LUU group had one case of long-term complication (one case of anastomotic stricture), there was no statistically significant difference between the groups (χ² = 1.493, P = 0.222). Both groups exhibited a trend towards improvement in the anteroposterior renal pelvic diameter (APD), ureter diameter (UD), and differential renal function (DRF) of the affected side before and after surgery. However, further analysis revealed no statistically significant differences in the changes in APD (ΔAPD; t=-0.032, P=0.962), changes in DRF (ΔDRF; Z=1.895, P=0.073), or changes in UD (ΔUD; t=1.832, P=0.079) between the two groups. Postoperative early complications in both groups primarily consisted of short-term recurrent urinary tract infections, which may be related to the presence of the ureteral stent. All cases improved following conservative treatment. The UR group experienced five cases of urinary tract infection. One patient developed acute urinary retention after stent removal and required re-catheterization for one week before normal urination resumed. In the LUU group, in addition to six cases of urinary tract infection, one case of anastomotic leakage was noted, which subsequently required percutaneous nephrostomy, with a good prognosis. During long-term follow-up, both groups presented various types of late complications, primarily including anastomotic stricture, recurrent urinary tract infections, and vesicoureteral reflux (VUR). Specifically, the UR group exhibited four complications: two patients suffered from recurrent urinary tract infections postoperatively; one patient was diagnosed with anastomotic stricture at the ureteral-bladder junction, whose renal function was suboptimal on diuretic renography and subsequently underwent partial nephrectomy 11 months post-surgery; another patient was diagnosed with VUR, also underwent partial nephrectomy 10 months post-surgery due to impaired renal function. Two patients in this group developed anastomotic stricture, but their renal function remained within acceptable limits according to diuretic renography, leading to a repeat Lich-Gregoir procedure one year postoperatively. In contrast, the LUU group had only one case of late complication, specifically anastomotic stricture accompanied by a decline in differential renal function (DRF), with this patient undergoing partial nephrectomy 13 months after surgery. No cases of stump syndrome were observed in either group. Table 2 Preoperative and postoperative comparison of LUU and UR groups LUU UR P Value APD, mm Pre 14.5（21，8.7） 17.5（23.3，12.5） ＜0.0001 Post 8.3（11.8，5.2） 11.2（14.1，6.2） UD, mm Pre 9.4（10.9，5.5） 10.5（12.6，8.9） ＜0.0001 Post 3.6（4.5，2.3） 2.3（5.2，1.4） DRF, % Pre 44.38（46.93，41.58） 42.26（46.15，40.52） ＜0.0001 Post 46.54（48.34，45.39） 46.57（48.82，44.73） Abbreviations and Acronyms: LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function ; Pre：preoperative；Post：postoperative Table 3 Comparison of LUU and UR groups LUU UR P Value Surgical duration, min 122±13.2 132±12.4 0.004 Intraoperative blood loss, ml 8.5±4.6 12.6±6.4 0.0196 Postoperative hospitalization, d 6.4±2.3 10.5±2.8 0.027 ureteral stent，case 30/45 20/35 0.383 ΔAPD, mm 6.5±8.4 6.2±9.1 0.962 ΔUD, mm 6.3±4.9 9.5±5.4 0.079 ΔDRF, % 2.16（0.52，4.64） 3.83（0.59，7.47） 0.073 Long-term complication, case 1/45 4/35 0.222 Abbreviations and Acronyms: LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function ; Pre：preoperative；Post：postoperative Discussion The pathological features of renal and ureteral duplication anomalies in children are complex and diverse. One subset nvolves lesions at the lower end of a single ureter on the same side, including abnormal positioning of the upper renal-ureteric orifice, proximal ureteral dilation, as well as potential bladder-ureteral reflux (VUR) associated with the lower kidney. Clinically, this condition often presents with a series of symptoms such as hydronephrosis, uncontrolled urinary leakage during intervals, abdominal pain, recurrent urinary tract infections, and VUR. If timely medical intervention is not provided, it may further lead to renal scarring and renal function impairment[9]. Currently, there is no universally accepted standard for surgical strategies regarding pediatric renal duplication, with discussions primarily focusing on whether to excise or preserve the renal unit. Jordan et al.[10] pioneered laparoscopic heminephrectomy in 1993 as an innovative approach to treat renal and ureteral duplication anomalies in children. Despite its significant efficacy, heminephrectomy is considered the preferred option for managing poorly functioning or malformed duplicated kidneys, yet it comes with risks, particularly concerning the potential injury to normal renal tissues, leading to vascular damage, vasospasm, and even infection of the ureteral stump[11, 12]. Hence, surgical procedures must be executed with meticulous care. In recent years, treatment strategies for renal and ureteral duplication anomalies have seen a trend among experts favoring the preservation of the affected kidney to minimize potential negative impacts on renal function. Kidney-preserving surgeries include transurethral endoscopic ureteral dilation, ureteroureterostomy, single ureteral bladder reimplantation, and common sheath ureteral reimplantation (CSUR). The ureteral dilation procedure, noted for its minimally invasive characteristics, has emerged as an ideal choice for treating recurrent urinary tract infections, voiding dysfunction, and in younger patients who are unsuitable for heminephrectomy or complex urinary reconstruction, showcasing unique advantages. However, literature also reports suboptimal outcomes for ureteral dilation, with approximately 30% to 50% of cases experiencing VUR postoperatively, and between 42% to 100% of children requiring additional surgical interventions[13]. Furthermore, CSUR is commonly employed; this technique cleverly avoids the dissection of closely adjacent ureters, effectively reducing potential damage to the blood supply of the ureters. Nonetheless, the success of this procedure hinges on constructing a sufficiently long and wide submucosal tunnel in the bladder, which poses a significant challenge in younger children with smaller bladder volumes, as inadequate tunnel length may considerably increase the risk of postoperative VUR. Lee et al.[14] conducted a study revealing that among 39 children with renal duplication undergoing CSUR, despite a high rate of alleviation of upper urinary tract dilation at 92.3%, 17.9% still required secondary surgeries due to long-term complications. In light of these factors, pediatric surgeons have gradually decreased reliance on CSUR, shifting towards more reliable treatment options such as UU and UR. The key to using ureteral reimplantation (UR) for treating renal duplication anomalies lies in the precise dissection of the upper and lower ureters within a common sheath, with particular attention to preserving the integrity of the normal ureters. Typically, dissection should extend only to the point where the two ureters share a wall, avoiding excessive separation that could impair the blood supply to the ureters. Common surgical techniques employed in UR include the modified Lich-Gregoir procedure performed extravesically and the Cohen and Politano-Leadbetter techniques performed intravesically, both of which have demonstrated high surgical success rates. However, in cases requiring the excision of ureteral dilation, the Cohen or Politano-Leadbetter procedures are often prioritized due to their specific technical advantages[15]. A study by Castagnetti et al.[16] indicated that UR treatment yielded satisfactory clinical outcomes for children with renal duplication, even in those with poor function of the upper kidney, showcasing significant efficacy. Nevertheless, the potential adverse effects of extensive lower urinary tract reconstruction surgeries performed during infancy on bladder function as the child grows warrant more attention and research[17]. In a cohort of 30 children who underwent UR, one case of acute urinary retention occurred post-catheter removal, possibly related to intraoperative damage to the distal ureter and the innervating nerves of the bladder muscular layer[18]. This condition was managed through catheterization, leading to a gradual return to normal urination after one week. Foley first reported the use of ureteroureterostomy (UU) for treating renal and ureteral duplication anomalies in 1928[19]. In recent years, with advancements in minimally invasive techniques and accumulated experience, laparoscopic ureteroureterostomy (LUU) has demonstrated advantages over traditional open surgical approaches, such as reduced tissue trauma, ample working space, and confirmed efficacy. Gerwinn et al.[20] suggested that LUU is a safe and effective treatment for pediatric renal duplication, serving as a viable alternative to common sheath ureteral reimplantation (CSUR). Mcleod et al.[21] noted that the prognostic outcomes of LUU are independent of the partial renal function of the affected kidney and its ureteral diameter, reaffirming its safety and effectiveness. The author believes that compared to single ureteral bladder reimplantation, ureteroureterostomy can avoid vascular and nerve injuries associated with the opening of the bladder during reimplantation, while also preventing potential obstruction at the anastomosis site or vesicoureteral reflux (VUR) that may occur during the establishment of an anti-reflux mechanism through ureteral embedding. The selection of the anastomosis site for LUU should be based on the surgeon's experience and preferences. The advantage of a proximal anastomosis lies in its ability to avoid excessive resection of the dilated ureter, as it only requires moderate adjustments at the anastomosis site, making it particularly suitable for severely tortuous and enlarged ureters. However, a potential risk is that if a stricture occurs postoperatively, subsequent surgeries may face challenges such as insufficient ureteral length or limitations in choosing the anastomosis site. Therefore, when dealing with mild to moderate dilation of the upper renal ureter, we prefer the distal horizontal anastomosis technique. This approach has a smaller anatomical scope, smooth operation, and does not require excessive resection of the diseased ureter, thus reducing surgical complexity and potential risks. Furthermore, distal anastomosis allows for more extensive excision of the duplicated ureter's residual stump, minimizing the risk of postoperative infection due to excess stump retention. During the anastomosis, a 6-0 absorbable suture is initially used to precisely stitch one needle at both the proximal and distal ureters for positioning. Subsequently, continuous suturing along the anterior and posterior edges of the ureter completes the end-to-side anastomosis, ensuring a tight and even junction. If necessary, a traction line may be placed through the abdominal wall to facilitate the lower renal ureter. Some surgeons also address the technical challenges posed by the narrower diameter of the recipient ureter by preemptively placing a D-J stent in the lower kidney under cystoscopy, followed by LUU after 2 to 4 weeks[9]. Gerwinn et al.[20] reported two cases (12.5%) of anastomotic leakage following LUU, with clinical presentations including febrile urinary tract infections and paralytic ileus. One case resolved with conservative treatment, while the other required percutaneous nephrostomy for recovery. In our study, among 35 children in the LUU group, there was only one case of anastomotic leakage, potentially linked to the surgeon's proficiency in laparoscopic pyeloplasty techniques. Regardless of the surgical approach employed, accurately identifying the duplicated ureters, meticulously ligating the upper ureter as distally as possible, selecting an appropriate anastomosis site, and avoiding ureteral twist and tension-free anastomosis are all critical factors for the success of the surgery. LUU and UR aim to preserve upper renal function to the greatest extent; however, maintaining long-term function of the upper kidney may carry the risk of renal hypertension. Several studies have indicated that there is no clear causal relationship between the hypertension observed in these children and renal dysplasia of the upper kidney. Instead, renal scarring resulting from febrile urinary tract infections (UTIs) has been identified as one of the significant factors contributing to hypertension[22]. In our study, due to the relatively short follow-up period, no cases of hypertension have emerged, and further tracking is needed to determine whether renal hypertension complicates long-term outcomes. Furthermore, while some literature has mentioned the potential for "yo-yo reflux," where urine may flow from the donor ureter back into the recipient ureter following end-to-side anastomosis, raising concerns about an increased risk of recurrent infections in the recipient ureter and kidney, this theory has not received conclusive evidence in subsequent, more in-depth studies. From the data in this study, it appears that the diameter of the donor ureter has decreased to varying degrees postoperatively, with no significant dilation observed in the recipient ureter, indirectly suggesting that "yo-yo" reflux is not occurring. In summary, both LUU and UR are effective surgical options for the treatment of complete renal and ureteral duplication anomalies in children. There are no significant differences between the two techniques regarding the number of stent placements, changes in the anteroposterior diameter of the affected upper renal pelvis before and after surgery, or improvements in differential renal function (DRF) of the affected kidney. Compared to UR, LUU is associated with shorter operative time, reduced intraoperative blood loss, and fewer postoperative hospital days. Additionally, since LUU does not involve the bladder, it results in less damage to the bladder in affected children, making it a procedure worth promoting in clinical practice. Declarations Author Contribution F is responsible for the research design of the paper, Y is responsible for literature retrieval, data collection and analysis, chart making and paper writing, and the discussion and analysis of the paper are jointly completed by F and Y References Horst M, Smith GH. Pelvi-ureteric junction obstruction in duplex kidneys. BJU Int 2008; 101: 1580-1584. DOI: 10.1111/j.1464-410X.2007.07386.x Sheth KR, White JT, Janzen N et al. Evaluating Outcomes of Differential Surgical Management of Nonfunctioning Upper Pole Renal Moieties in Duplex Collecting Systems. Urology 2019; 123: 198-203. DOI: 10.1016/j.urology.2018.06.028 Kawal T, Srinivasan AK, Talwar R et al. Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter? J Pediatr Urol 2019; 15: 50.e51-50.e56. DOI: 10.1016/j.jpurol.2018.08.012 Yin X, Yang Y. Clinical manifestations and treatment of duplex kidneys in 82 children. Chinese Journal of Applied Clinical Pediatrics 2016; 1803-1805. 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Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2024 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Revision requested 20 Oct, 2024 Reviews received at journal 16 Sep, 2024 Reviewers agreed at journal 07 Sep, 2024 Reviewers invited by journal 05 Sep, 2024 Editor assigned by journal 19 Aug, 2024 Submission checks completed at journal 19 Aug, 2024 First submitted to journal 18 Aug, 2024 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. We do this by developing innovative software and high quality services for the global research community. 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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-4932918","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":354263588,"identity":"75a280c9-6e8a-4b2a-8821-7700acc5c636","order_by":0,"name":"bin yu","email":"","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":false,"prefix":"","firstName":"bin","middleName":"","lastName":"yu","suffix":""},{"id":354263589,"identity":"a2c9a9ff-796d-4556-98e0-9505b68a6d0b","order_by":1,"name":"yingzhong fan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYBAC9gYgkQDEBiDehwoJOXlCWngOIGlhnHHGwtiwgRgtDFAtzLxtFYkMB3CrhmhhP3tM4uGOWntz9t7DL3jnSSQwNjA/fHQDnxaevDSJxDPHmS17zqVZSG6TyGNnYDM2zsGjxZ4hx0wise0Ym8GNHDMDw20SxYwNPGzS+LTw8L8Ba+EBa0mcI5HYcICQFgmwLTUSQC3GDw42EKXljbFFYtsBA4MzZ8wYG45JGBs2E/ALD3+O4c2fbXX2Bsd7jD//qamTk2dvfvgYnxYgYJFgYDgMYrBJgPnM+JWDlXxgYKiDMUbBKBgFo2AUYAIAuwxK+eERVw0AAAAASUVORK5CYII=","orcid":"","institution":"First Affiliated Hospital of Zhengzhou University","correspondingAuthor":true,"prefix":"","firstName":"yingzhong","middleName":"","lastName":"fan","suffix":""}],"badges":[],"createdAt":"2024-08-18 10:23:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4932918/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4932918/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00383-024-05908-5","type":"published","date":"2024-11-27T15:58:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66572220,"identity":"18c848e4-4f1f-4f1c-808e-114dd0b6f3c0","added_by":"auto","created_at":"2024-10-14 11:53:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":320769,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG70.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/cf204926928fd0b88b0ec92b.png"},{"id":66572216,"identity":"907d29e7-5a1e-4102-9189-3274b52ab017","added_by":"auto","created_at":"2024-10-14 11:53:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":339699,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG71.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/97e034e18a5499639920bf8d.png"},{"id":66572164,"identity":"7b2c8e2e-cb02-4f1e-84bc-287c1eeb9de4","added_by":"auto","created_at":"2024-10-14 11:53:53","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":363115,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG72.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/eb091f6022fd975ca3537294.png"},{"id":66572218,"identity":"9e9dc95f-0474-461a-a4e9-5430b0e907e5","added_by":"auto","created_at":"2024-10-14 11:53:56","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":332197,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG73.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/b8b35f4434a5557a65d321d4.png"},{"id":66572614,"identity":"729ccbb7-1600-4a81-9aa0-420f354551bb","added_by":"auto","created_at":"2024-10-14 12:01:56","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":286300,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG74.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/0cb063d616e291ce6fe862ac.png"},{"id":66572219,"identity":"e067ee99-1823-44be-ad77-9f86e6b87d2d","added_by":"auto","created_at":"2024-10-14 11:53:56","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":425264,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG75.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/1da12e03a1a14acd530d8461.png"},{"id":66572197,"identity":"3e352266-477e-4679-a996-422e3ff209e3","added_by":"auto","created_at":"2024-10-14 11:53:55","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":394894,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG76.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/a9e55dba6aac5e66f2ae6284.png"},{"id":66572615,"identity":"031c9d95-99eb-4de8-8dd4-dd0e7e259dca","added_by":"auto","created_at":"2024-10-14 12:01:56","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":485011,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"WechatIMG77.png","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/052511f2a377e21495802126.png"},{"id":70388695,"identity":"2ae10df5-a8b8-4a7c-bbbf-8b11cadee495","added_by":"auto","created_at":"2024-12-02 17:26:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5457763,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4932918/v1/6dd3ba73-dd82-46c8-8346-f6475f6d9479.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Comparative Study on the Efficacy of Laparoscopic Ureteroureterostomy versus Single Ureteral Bladder Reimplantation in Treating Pediatric Complete Renal Duplication","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRenal-ureteral duplication malformation is the most common renal anomaly in children[1], with an incidence reported at approximately 0.8%[2]. It is more frequently observed in females than in males[3], and unilateral cases are more common than bilateral ones, with no significant difference in the incidence between the left and right sides. Additionally, children with duplicated kidneys often present with associated ureteral anomalies, such as ureteral terminal dilatation and ectopic ureteral openings. Given the complex and diverse complications associated with duplicated kidneys, there is currently no unified standard for the diagnosis and treatment of this condition; management often requires a comprehensive assessment based on differential renal function and concomitant ureteral abnormalities[4]. The primary treatment options for preserving the upper pole of the kidney in cases of renal duplication include: ① transurethral endoscopic ureteral resection; ②Ureteroureterostomy; ③ lower urinary tract reconstruction. In cases where the upper pole kidney has poor or non-functional capabilities, partial nephrectomy may also be considered[5, 6]. This study aims to investigate the safety and efficacy of\u0026nbsp;laparoscopic\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eUreteroureterostomy (LUU) and single ureteral bladder reimplantation (UR) in treating pediatric patients with complete renal-ureteral duplication malformation, providing clinical evidence for the rational selection of surgical methods.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eClinical Data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe collected clinical data from 80 pediatric patients diagnosed with complete renal-ureteral duplication malformation at the First Affiliated Hospital of Zhengzhou University between January 2016 and December 2022. Preoperative diagnosis was confirmed through imaging studies, including urinary system ultrasound, diuretic renal scintigraphy, CT urogram (CTU), voiding cystourethrogram (VCUG), and magnetic resonance urography (MRU). All cases were unilateral. Patients were categorized based on surgical approach into the laparoscopic ureteroureterostomy group (LUU group, n=45) and the single ureteral reimplantation group (UR group, n=35). Detailed preoperative clinical data for both groups are summarized in Tables 1.\u003c/p\u003e\n\u003cp\u003eInclusion criteria were as follows: ① definitive preoperative diagnosis of complete renal-ureteral duplication malformation with concomitant ipsilateral ectopic ureteral openings or ureteral dilatation; exclusion of cases with simultaneous lesions in both ureters on the same side; ② progressive worsening of hydronephrosis due to duplicated kidneys; ③ presence of recurrent urinary tract infections, urinary incontinence during intervals, flank or abdominal pain. Exclusion criteria included: ① distal \u0026ldquo;Y\u0026rdquo;-type ureteral duplication malformation; ② findings of renal developmental dysplasia or poor function in the upper pole as indicated by diuretic renal scintigraphy or CTU; ③ acute phase of urinary tract infection or affected kidney diagnosed as pyonephrosis. The differential renal function (DRF) values were calculated considering the affected side\u0026apos;s upper and lower poles together before and after surgery. Follow-up evaluations included urinary system ultrasound at 1, 3, and 12 months postoperatively; diuretic renal scintigraphy and CTU at 6 months postoperative. For children undergoing ureteral bladder reimplantation who did not present urinary tract infection symptoms postoperatively, routine follow-up VCUG was not scheduled. This study received formal approval from the Institutional Review Board of the First Affiliated Hospital of Zhengzhou University (Approval No: 2023-KY-0573), and all families of participating patients were fully informed about the study\u0026apos;s content and provided written informed consent.\u003c/p\u003e\n\u003cp\u003eTable1 Clinical profiles of 80 children with complete duplicated collecting systems\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003eLUU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003eUR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.57894736842105%\" colspan=\"2\"\u003e\n \u003cp\u003eNumber of cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.927835051546392%\" colspan=\"2\"\u003e\n \u003cp\u003eAge, months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.835051546391753%\" colspan=\"2\"\u003e\n \u003cp\u003e12.85（2,85）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.835051546391753%\" colspan=\"2\"\u003e\n \u003cp\u003e13.76（3,83）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.57894736842105%\" colspan=\"2\"\u003e\n \u003cp\u003eGender(M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e29/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e22/13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.57894736842105%\" colspan=\"2\"\u003e\n \u003cp\u003eLaterality（L/R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e24/21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e19/16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eDiagnosis, case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.57894736842105%\" colspan=\"2\"\u003e\n \u003cp\u003eureteral ectopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eureterocele\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.57894736842105%\" colspan=\"2\"\u003e\n \u003cp\u003eObstructed ureter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.68421052631579%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eUti, case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eAPD,mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e16.4\u0026plusmn;10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e18.5\u0026plusmn;8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e0.201\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eUD, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e9.5\u0026plusmn;5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e10.7\u0026plusmn;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.02127659574468%\"\u003e\n \u003cp\u003eDRF, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e43.65\u0026plusmn;4.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e42.59\u0026plusmn;6.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.829787234042554%\"\u003e\n \u003cp\u003e0.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations and Acronyms: LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll pediatric patients with urinary tract infections underwent surgical treatment after controlling the infection with antibiotics.\u003c/p\u003e\n\u003cp\u003eIn the LUU group: general anesthesia was induced using a combination of intravenous and inhalational agents. Following the induction of anesthesia, patients were positioned in a lithotomy position, and cystoscopy was performed to assess the smoothness of the bladder mucosa and the location of the ureteral openings. If the recipient ureter was found to be relatively narrow, a stent was placed into the recipient ureter via the cystoscope. The position was then changed to a head-down tilt, and three 5 mm trocars were inserted at the subumbilical level laterally to the rectus abdominis muscles to establish pneumoperitoneum. Using the stent as a guide, the anatomical relationship between the upper and lower ureters was clarified at the pelvic inlet. An electric hook was utilized to open the posterior peritoneum at the intersection of the ureter and iliac vessels, and the tortuous dilated ureter was freed from surrounding tissue until it was tension-free. The dilated ureter was ligated across at the point anterior to the iliac vessels, and a longitudinal incisional cut was made on the lateral wall of the lower ureter, with the incision length matched to the diameter of the diseased segment of the ureter. Through the pre-placed stent, the anatomical relationship between the upper and lower ureters was re-confirmed. The donor ureter was anastomosed to the recipient ureter using 5-0 absorbable sutures in a tension-free, non-tortuous manner to form a Y-shaped ureter. If the upper ureter had a diameter \u0026ge; 1.5cm, non-tortuous manner to form a Y-shaped ureter. If the upper ureter had a diameter \u0026ge; 1.5cm, the ureter would be trimmed prior to anastomosis. The residual ureteral stump was meticulously mobilized and expanded to the junction of the ureter and bladder or to the common sheath if both ureters were present, and this was secured with sutures. Finally, the pelvic peritoneum was closed and repaired.\u003c/p\u003e\n\u003cp\u003eIn the UR group: Following the induction of anesthesia, patients were positioned supine with a urinary catheter left in place. Three 5 mm trocars were inserted at the subumbilical level laterally to the rectus abdominis muscles to establish pneumoperitoneum. The posterior peritoneum above the bladder was opened, and the tortuous dilated ureter was freed until reaching the junction of the ureter and bladder or the common sheath of both ureters. The bladder\u0026apos;s posterior lateral muscle layer was incised along the natural course of the ureter, exposing the bladder mucosa. Physiological saline was injected through the catheter to distend the bladder mucosa, and the bladder muscle layer was dissected laterally to ensure that the length of the submucosal tunnel was 4 to 5 times the diameter of the reimplanted ureter, with a width twice that size. The upper ureter was ligated at the bladder entrance and subsequently transected. The distal end of the ureter was trimmed to achieve an opening diameter of 4 to 6 mm. An incision was made at the proximal end of the original bladder entrance, and the Lich-Gregoir[7]\u0026nbsp;method was employed for the burying suture technique, followed by interrupted sutures to close the bladder muscle layer. For patients with significant ureteral ballooning (a total of 13 cases in this group), electrocautery was performed around the protrusion using a cystoscope before proceeding with reimplantation according to the Cohen[8]\u0026nbsp;technique. If the diameter of the upper ureter reached or exceeded 1.5 cm, it was first trimmed to reduce the diameter to between 6 and 8 mm, after which a stent was placed percutaneously, followed by ureter reconstruction (UR) surgery. In the UR group, a total of 20 patients underwent ureteral trimming and reconstruction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStented ureters placed during the operation were removed via cystoscopy 6 to 8 weeks postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were meticulously recorded and compared between the LUU group and UR group regarding surgical-related metrics. This included operation time, intraoperative blood loss, postoperative complications, length of hospital stay, as well as postoperative measurements such as the anteroposterior renal pelvic diameter (APD) of the affected upper kidney, ureter diameter (UD), and differential renal function (DRF) of the affected side.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis for this study was conducted using SPSS29.0 statistical software. Continuous variables that followed a normal distribution were presented as means \u0026plusmn; standard deviations (X̅ \u0026plusmn; S), with inter-group differences assessed using independent samples t-tests and intra-group differences analyzed through paired t-test. For continuous variables not conforming to a normal distribution, medians (M) and interquartile ranges (Q1, Q3) were utilized for description, with rank-sum tests employed to compare mean differences between the two groups. Additionally, gender and side were treated as categorical variables, and comparisons of rates between two samples were performed using chi-square tests (X\u0026sup2; test). P\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe LUU group demonstrated significantly shorter operation times (t=3.480, P=0.004), reduced intraoperative blood loss (t=-2.465, P=0.0196), and fewer postoperative hospital days (t=2.308, P=0.027) compared to the UR group, with all differences being statistically significant (Tables 2 and 3). The number of stent placements in the LUU group compared to the UR group showed no statistically significant difference (\u0026chi;\u0026sup2;=0.762, P=0.383). In the UR group, there were four cases of long-term complications (two cases of anastomotic stricture, one case of vesicoureteral reflux, and one case of recurrent urinary tract infection), while the LUU group had one case of long-term complication (one case of anastomotic stricture), there was no statistically significant difference between the groups (\u0026chi;\u0026sup2; = 1.493, P = 0.222). Both groups exhibited a trend towards improvement in the anteroposterior renal pelvic diameter (APD), ureter diameter (UD), and differential renal function (DRF) of the affected side before and after surgery. However, further analysis revealed no statistically significant differences in the changes in APD (\u0026Delta;APD; t=-0.032, P=0.962), changes in DRF (\u0026Delta;DRF; Z=1.895, P=0.073), or changes in UD (\u0026Delta;UD; t=1.832, P=0.079) between the two groups.\u003c/p\u003e\n\u003cp\u003ePostoperative early complications in both groups primarily consisted of short-term recurrent urinary tract infections, which may be related to the presence of the ureteral stent. All cases improved following conservative treatment. The UR group experienced five cases of urinary tract infection. One patient developed acute urinary retention after stent removal and required re-catheterization for one week before normal urination resumed. In the LUU group, in addition to six cases of urinary tract infection, one case of anastomotic leakage was noted, which subsequently required percutaneous nephrostomy, with a good prognosis. During long-term follow-up, both groups presented various types of late complications, primarily including anastomotic stricture, recurrent urinary tract infections, and vesicoureteral reflux (VUR). Specifically, the UR group exhibited four complications: two patients suffered from recurrent urinary tract infections postoperatively; one patient was diagnosed with anastomotic stricture at the ureteral-bladder junction, whose renal function was suboptimal on diuretic renography and subsequently underwent partial nephrectomy 11 months post-surgery; another patient was diagnosed with VUR, also underwent partial nephrectomy 10 months post-surgery due to impaired renal function. Two patients in this group developed anastomotic stricture, but their renal function remained within acceptable limits according to diuretic renography, leading to a repeat Lich-Gregoir procedure one year postoperatively. In contrast, the LUU group had only one case of late complication, specifically anastomotic stricture accompanied by a decline in differential renal function (DRF), with this patient undergoing partial nephrectomy 13 months after surgery. No cases of stump syndrome were observed in either group.\u003c/p\u003e\n\u003cp\u003eTable 2 Preoperative and postoperative comparison of LUU and UR groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eLUU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eUR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eAPD, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e14.5（21，8.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e17.5（23.3，12.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" rowspan=\"2\"\u003e\n \u003cp\u003e＜0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003ePost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e8.3（11.8，5.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e11.2（14.1，6.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eUD, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e9.4（10.9，5.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e10.5（12.6，8.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" rowspan=\"2\"\u003e\n \u003cp\u003e＜0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003ePost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e3.6（4.5，2.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e2.3（5.2，1.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003eDRF, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\n \u003cp\u003ePre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e44.38（46.93，41.58）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.571428571428573%\" colspan=\"2\"\u003e\n \u003cp\u003e42.26（46.15，40.52）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.285714285714286%\" rowspan=\"2\"\u003e\n \u003cp\u003e＜0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003ePost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e46.54（48.34，45.39）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" colspan=\"2\"\u003e\n \u003cp\u003e46.57（48.82，44.73）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations and Acronyms:\u0026nbsp;LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function\u0026nbsp;; Pre：preoperative；Post：postoperative\u003c/p\u003e\n\u003cp\u003eTable 3 Comparison of LUU and UR groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003eLUU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003eUR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.343434343434346%\" colspan=\"2\"\u003e\n \u003cp\u003eSurgical duration, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e122\u0026plusmn;13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e132\u0026plusmn;12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.343434343434346%\" colspan=\"2\"\u003e\n \u003cp\u003eIntraoperative blood loss, ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e8.5\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e12.6\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.0196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.343434343434346%\" colspan=\"2\"\u003e\n \u003cp\u003ePostoperative hospitalization, d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e6.4\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e10.5\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.343434343434346%\" colspan=\"2\"\u003e\n \u003cp\u003eureteral stent，case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e30/45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e20/35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.383\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\n \u003cp\u003e\u0026Delta;APD, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e6.5\u0026plusmn;8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e6.2\u0026plusmn;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.962\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\n \u003cp\u003e\u0026Delta;UD, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e6.3\u0026plusmn;4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e9.5\u0026plusmn;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\n \u003cp\u003e\u0026Delta;DRF, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.171717171717173%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e2.16（0.52，4.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.262626262626263%\" colspan=\"2\"\u003e\n \u003cp\u003e3.83（0.59，7.47）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.343434343434346%\" colspan=\"2\"\u003e\n \u003cp\u003eLong-term complication, case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e1/45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e4/35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.131313131313131%\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations and Acronyms: LUU：laparoscopic ureteroureterostomy；UR: ureteral reimplantation；APD：Anterio-posterior renal pelvic diameter；UD：ureteral diameter；DRF：Differential Renal Function ; Pre：preoperative；Post：postoperative\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe pathological features of renal and ureteral duplication anomalies in children are complex and diverse. One subset nvolves lesions at the lower end of a single ureter on the same side, including abnormal positioning of the upper renal-ureteric orifice, proximal ureteral dilation, as well as potential bladder-ureteral reflux (VUR) associated with the lower kidney. Clinically, this condition often presents with a series of symptoms such as hydronephrosis, uncontrolled urinary leakage during intervals, abdominal pain, recurrent urinary tract infections, and VUR. If timely medical intervention is not provided, it may further lead to renal scarring and renal function impairment[9]. Currently, there is no universally accepted standard for surgical strategies regarding pediatric renal duplication, with discussions primarily focusing on whether to excise or preserve the renal unit. Jordan et al.[10]\u0026nbsp;pioneered laparoscopic heminephrectomy in 1993 as an innovative approach to treat renal and ureteral duplication anomalies in children. Despite its significant efficacy, heminephrectomy is considered the preferred option for managing poorly functioning or malformed duplicated kidneys, yet it comes with risks, particularly concerning the potential injury to normal renal tissues, leading to vascular damage, vasospasm, and even infection of the ureteral stump[11, 12]. Hence, surgical procedures must be executed with meticulous care. In recent years, treatment strategies for renal and ureteral duplication anomalies have seen a trend among experts favoring the preservation of the affected kidney to minimize potential negative impacts on renal function. Kidney-preserving surgeries include transurethral endoscopic ureteral dilation,\u0026nbsp;ureteroureterostomy, single ureteral bladder reimplantation, and common sheath ureteral reimplantation (CSUR). The ureteral dilation procedure, noted for its minimally invasive characteristics, has emerged as an ideal choice for treating recurrent urinary tract infections, voiding dysfunction, and in younger patients who are unsuitable for heminephrectomy or complex urinary reconstruction, showcasing unique advantages. However, literature also reports suboptimal outcomes for ureteral dilation, with approximately 30% to 50% of cases experiencing VUR postoperatively, and between 42% to 100% of children requiring additional surgical interventions[13]. Furthermore, CSUR is commonly employed; this technique cleverly avoids the dissection of closely adjacent ureters, effectively reducing potential damage to the blood supply of the ureters. Nonetheless, the success of this procedure hinges on constructing a sufficiently long and wide submucosal tunnel in the bladder, which poses a significant challenge in younger children with smaller bladder volumes, as inadequate tunnel length may considerably increase the risk of postoperative VUR. Lee et al.[14]\u0026nbsp;conducted a study revealing that among 39 children with renal duplication undergoing CSUR, despite a high rate of alleviation of upper urinary tract dilation at 92.3%, 17.9% still required secondary surgeries due to long-term complications. In light of these factors, pediatric surgeons have gradually decreased reliance on CSUR, shifting towards more reliable treatment options such as UU and UR.\u003c/p\u003e\n\u003cp\u003eThe key to using ureteral reimplantation (UR) for treating renal duplication anomalies lies in the precise dissection of the upper and lower ureters within a common sheath, with particular attention to preserving the integrity of the normal ureters. Typically, dissection should extend only to the point where the two ureters share a wall, avoiding excessive separation that could impair the blood supply to the ureters. Common surgical techniques employed in UR include the modified Lich-Gregoir procedure performed extravesically and the Cohen and Politano-Leadbetter techniques performed intravesically, both of which have demonstrated high surgical success rates. However, in cases requiring the excision of ureteral dilation, the Cohen or Politano-Leadbetter procedures are often prioritized due to their specific technical advantages[15]. A study by Castagnetti et al.[16]\u0026nbsp;indicated that UR treatment yielded satisfactory clinical outcomes for children with renal duplication, even in those with poor function of the upper kidney, showcasing significant efficacy. Nevertheless, the potential adverse effects of extensive lower urinary tract reconstruction surgeries performed during infancy on bladder function as the child grows warrant more attention and research[17]. In a cohort of 30 children who underwent UR, one case of acute urinary retention occurred post-catheter removal, possibly related to intraoperative damage to the distal ureter and the innervating nerves of the bladder muscular layer[18]. This condition was managed through catheterization, leading to a gradual return to normal urination after one week.\u003c/p\u003e\n\u003cp\u003eFoley first reported the use of ureteroureterostomy (UU) for treating renal and ureteral duplication anomalies in 1928[19]. In recent years, with advancements in minimally invasive techniques and accumulated experience, laparoscopic ureteroureterostomy (LUU) has demonstrated advantages over traditional open surgical approaches, such as reduced tissue trauma, ample working space, and confirmed efficacy. Gerwinn et al.[20]\u0026nbsp;suggested that LUU is a safe and effective treatment for pediatric renal duplication, \u0026nbsp;serving as a viable alternative to common sheath ureteral reimplantation (CSUR). Mcleod et al.[21]\u0026nbsp;noted that the prognostic outcomes of LUU are independent of the partial renal function of the affected kidney and its ureteral diameter, reaffirming its safety and effectiveness. The author believes that compared to single ureteral bladder reimplantation,\u0026nbsp;ureteroureterostomy\u0026nbsp;can avoid vascular and nerve injuries associated with the opening of the bladder during reimplantation, while also preventing potential obstruction at the anastomosis site or vesicoureteral reflux (VUR) that may occur during the establishment of an anti-reflux mechanism through ureteral embedding.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe selection of the anastomosis site for LUU should be based on the surgeon\u0026apos;s experience and preferences. The advantage of a proximal anastomosis lies in its ability to avoid excessive resection of the dilated ureter, as it only requires moderate adjustments at the anastomosis site, making it particularly suitable for severely tortuous and enlarged ureters. However, a potential risk is that if a stricture occurs postoperatively, subsequent surgeries may face challenges such as insufficient ureteral length or limitations in choosing the anastomosis site. Therefore, when dealing with mild to moderate dilation of the upper renal ureter, we prefer the distal horizontal anastomosis technique. This approach has a smaller anatomical scope, smooth operation, and does not require excessive resection of the diseased ureter, thus reducing surgical complexity and potential risks. Furthermore, distal anastomosis allows for more extensive excision of the duplicated ureter\u0026apos;s residual stump, minimizing the risk of postoperative infection due to excess stump retention. During the anastomosis, a 6-0 absorbable suture is initially used to precisely stitch one needle at both the proximal and distal ureters for positioning. Subsequently, continuous suturing along the anterior and posterior edges of the ureter completes the end-to-side anastomosis, ensuring a tight and even junction. If necessary, a traction line may be placed through the abdominal wall to facilitate the lower renal ureter. Some surgeons also address the technical challenges posed by the narrower diameter of the recipient ureter by preemptively placing a D-J stent in the lower kidney under cystoscopy, followed by LUU after 2 to 4 weeks[9]. Gerwinn et al.[20]\u0026nbsp;reported two cases (12.5%) of anastomotic leakage following LUU, with clinical presentations including febrile urinary tract infections and paralytic ileus. One case resolved with conservative treatment, while the other required percutaneous nephrostomy for recovery. In our study, among 35 children in the LUU group, there was only one case of anastomotic leakage, potentially linked to the surgeon\u0026apos;s proficiency in laparoscopic pyeloplasty techniques. Regardless of the surgical approach employed, accurately identifying the duplicated ureters, meticulously ligating the upper ureter as distally as possible, selecting an appropriate anastomosis site, and avoiding ureteral twist and tension-free anastomosis are all critical factors for the success of the surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLUU and UR aim to preserve upper renal function to the greatest extent; however, maintaining long-term function of the upper kidney may carry the risk of renal hypertension. Several studies have indicated that there is no clear causal relationship between the hypertension observed in these children and renal dysplasia of the upper kidney. Instead, renal scarring resulting from febrile urinary tract infections (UTIs) has been identified as one of the significant factors contributing to hypertension[22]. In our study, due to the relatively short follow-up period, no cases of hypertension have emerged, and further tracking is needed to determine whether renal hypertension complicates long-term outcomes. Furthermore, while some literature has mentioned the potential for \u0026quot;yo-yo reflux,\u0026quot; where urine may flow from the donor ureter back into the recipient ureter following end-to-side anastomosis, raising concerns about an increased risk of recurrent infections in the recipient ureter and kidney, this theory has not received conclusive evidence in subsequent, more in-depth studies. From the data in this study, it appears that the diameter of the donor ureter has decreased to varying degrees postoperatively, with no significant dilation observed in the recipient ureter, indirectly suggesting that \u0026quot;yo-yo\u0026quot; reflux is not occurring.\u003c/p\u003e\n\u003cp\u003eIn summary, both LUU and UR are effective surgical options for the treatment of complete renal and ureteral duplication anomalies in children. There are no significant differences between the two techniques regarding the number of stent placements, changes in the anteroposterior diameter of the affected upper renal pelvis before and after surgery, or improvements in differential renal function (DRF) of the affected kidney. Compared to UR, LUU is associated with shorter operative time, reduced intraoperative blood loss, and fewer postoperative hospital days. Additionally, since LUU does not involve the bladder, it results in less damage to the bladder in affected children, making it a procedure worth promoting in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eF is responsible for the research design of the paper, Y is responsible for literature retrieval, data collection and analysis, chart making and paper writing, and the discussion and analysis of the paper are jointly completed by F and Y\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHorst M, Smith GH. Pelvi-ureteric junction obstruction in duplex kidneys. BJU Int 2008; 101: 1580-1584. DOI: 10.1111/j.1464-410X.2007.07386.x\u003c/li\u003e\n\u003cli\u003eSheth KR, White JT, Janzen N et al. Evaluating Outcomes of Differential Surgical Management of Nonfunctioning Upper Pole Renal Moieties in Duplex Collecting Systems. Urology 2019; 123: 198-203. DOI: 10.1016/j.urology.2018.06.028\u003c/li\u003e\n\u003cli\u003eKawal T, Srinivasan AK, Talwar R et al. Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter? J Pediatr Urol 2019; 15: 50.e51-50.e56. DOI: 10.1016/j.jpurol.2018.08.012\u003c/li\u003e\n\u003cli\u003eYin X, Yang Y. Clinical manifestations and treatment of duplex kidneys in 82 children. Chinese Journal of Applied Clinical Pediatrics 2016; 1803-1805. \u003c/li\u003e\n\u003cli\u003eJayram G, Roberts J, Hernandez A et al. Outcomes and fate of the remnant moiety following laparoscopic heminephrectomy for duplex kidney: a multicenter review. J Pediatr Urol 2011; 7: 272-275. DOI: 10.1016/j.jpurol.2011.02.029\u003c/li\u003e\n\u003cli\u003eSakellaris G, Kumara S, Cervellione RM et al. Outcome study of upper pole heminephroureterectomy in children. Int Urol Nephrol 2011; 43: 279-282. DOI: 10.1007/s11255-010-9869-6\u003c/li\u003e\n\u003cli\u003eGregoir W, Vanregemorter G. [CONGENITAL VESICO-URETERAL REFLUX]. Urol Int 1964; 18: 122-136. DOI: 10.1159/000279233\u003c/li\u003e\n\u003cli\u003eSoh S, Kobori Y, Shin T et al. Transvesicoscopic ureteral reimplantation: Politano-Leadbetter versus Cohen technique. Int J Urol 2015; 22: 394-399. DOI: 10.1111/iju.12702\u003c/li\u003e\n\u003cli\u003eWong NC, Braga LH. Open ureteroureterostomy for repair of upper-pole ectopic ureters in children with duplex systems: is stenting really necessary? J Pediatr Urol 2019; 15: 72.e71-72.e77. DOI: 10.1016/j.jpurol.2018.10.014\u003c/li\u003e\n\u003cli\u003eJordan GH, Winslow BH. Laparoendoscopic upper pole partial nephrectomy with ureterectomy. J Urol 1993; 150: 940-943. DOI: 10.1016/s0022-5347(17)35656-2\u003c/li\u003e\n\u003cli\u003eLee YS, Hah YS, Kim MJ et al. Factors associated with complications of the ureteral stump after proximal ureteroureterostomy. J Urol 2012; 188: 1890-1894. DOI: 10.1016/j.juro.2012.07.015\u003c/li\u003e\n\u003cli\u003eAgarwal D, Kandpal DK, Chowdhary SK. Laparoscopic ipsilateral ureteroureterostomy for the management of children with duplication anomalies. J Indian Assoc Pediatr Surg 2016; 21: 92-93. DOI: 10.4103/0971-9261.158094\u003c/li\u003e\n\u003cli\u003eJesus LE, Farhat WA, Amarante AC et al. Clinical evolution of vesicoureteral reflux following endoscopic puncture in children with duplex system ureteroceles. J Urol 2011; 186: 1455-1458. DOI: 10.1016/j.juro.2011.05.057\u003c/li\u003e\n\u003cli\u003eLee YS, Im YJ, Shin SH et al. Complications after common sheath reimplantation in pediatric patients with complicated duplex system. Urology 2015; 85: 457-462. DOI: 10.1016/j.urology.2014.10.014\u003c/li\u003e\n\u003cli\u003ePersky L, Hampel N. Simplified Technique for Ureteroneocystostomy: A modification of Politano-Leadbetter operation. Urol Int 1977; 32: 368-372. DOI: 10.1159/000280152\u003c/li\u003e\n\u003cli\u003eCastagnetti M, Canali R, Mastrocinque G et al. Dismembered extravesical reimplantation of dilated upper pole ectopic ureters in duplex systems. J Pediatr Surg 2013; 48: 459-463. DOI: 10.1016/j.jpedsurg.2012.11.050\u003c/li\u003e\n\u003cli\u003eWang Jinbin FX, Chen Zhoutong, Geng Hongquan. Comparison of single ureteral reimplantation and ipsilateral ureteroureterostomy for ureteral duplication in Children. J Clin Ped Sur 2022; 21: 341-346. DOI: 10.3760/cma.j.cn101785-202104010-009\u003c/li\u003e\n\u003cli\u003eBustangi N, Kallas Chemaly A, Scalabre A et al. Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy. Front Pediatr 2018; 6: 388. DOI: 10.3389/fped.2018.00388\u003c/li\u003e\n\u003cli\u003eFoley FEB. Uretero-Ureterostomy. As Applied to Obstructions of the Duplicated Upper Urinary Tract. Journal of Urology 1928; 20: 109-120. DOI: 10.1016/s0022-5347(17)73140-0\u003c/li\u003e\n\u003cli\u003eGerwinn T, Gnannt R, Weber DM et al. Laparoscopic Ureteroureterostomy vs. Common Sheath Ureteral Reimplantation in Children With Duplex Kidney Anomalies. Front Pediatr 2021; 9: 637544. DOI: 10.3389/fped.2021.637544\u003c/li\u003e\n\u003cli\u003eMcLeod DJ, Alpert SA, Ural Z et al. Ureteroureterostomy irrespective of ureteral size or upper pole function: a single center experience. J Pediatr Urol 2014; 10: 616-619. DOI: 10.1016/j.jpurol.2014.05.003\u003c/li\u003e\n\u003cli\u003eBoysen WR, Ellison JS, Kim C et al. Multi-Institutional Review of Outcomes and Complications of Robot-Assisted Laparoscopic Extravesical Ureteral Reimplantation for Treatment of Primary Vesicoureteral Reflux in Children. J Urol 2017; 197: 1555-1561. DOI: 10.1016/j.juro.2017.01.062\u003c/li\u003e\n\u003c/ol\u003e"}],"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":"Laparoscopy, Ureteroureterostomy, Ureteral Reimplantation, Duplex kidney, Pediatric","lastPublishedDoi":"10.21203/rs.3.rs-4932918/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4932918/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To explore the therapeutic value of laparoscopic\u003cstrong\u003e \u003c/strong\u003eureteroureterostomy compared to single ureteral bladder reimplantation in the treatment of pediatric complete renal duplication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This retrospective study included 80 pediatric patients with complete renal duplication who underwent surgical treatment at the First Affiliated Hospital of Zhengzhou University from January 2015 to December 2022. Patients were divided into two groups based on the surgical approach: the laparoscopic\u003cstrong\u003e \u003c/strong\u003eureteroureterostomy group (LUU group, n=45) and the single ureteral bladder reimplantation group (UR group, n=35). The two groups were compared in terms of operative time, intraoperative blood loss, number of stent placements, postoperative length of hospital stay, changes in ante-posterior diameter (APD) of the affected upper kidney pelvis before and after surgery, changes in upper ureteral diameter (UD), and variations in renal function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe LUU group demonstrated significantly shorter operative time (t=3.480, P=0.004), less intraoperative blood loss (t=-2.465, P=0.0196), and reduced postoperative length of stay (t=2.308, P=0.027) compared to the UR group. There was no significant difference between the two groups regarding the number of stent placements (x²=0.762, P=0.383). The UR group had four cases of long-term complications (two cases of anastomotic stricture, one case of vesicoureteral reflux, and one case of recurrent urinary tract infection), while the LUU group experienced one case of long-term complication (one case of anastomotic stricture), with no significant difference between groups (x²=1.493, P=0.222). Both groups showed significant improvement in preoperative and postoperative APD, UD, and affected side differential renal function (DRF). However, the differences in improvement values for upper kidney pelvis APD (ΔAPD; t=-0.032, P=0.962), differential renal function (ΔDRF; Z=1.895, P=0.073), and ureteral diameter (ΔUD; t=1.832, P=0.079) were not statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBoth LUU and UR procedures are safe and effective in treating pediatric complete renal duplication. Compared to UR, LUU results in shorter operative time, less intraoperative blood loss, and reduced postoperative length of stay, while also causing less damage to the bladder.\u003c/p\u003e","manuscriptTitle":"A Comparative Study on the Efficacy of Laparoscopic Ureteroureterostomy versus Single Ureteral Bladder Reimplantation in Treating Pediatric Complete Renal Duplication","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-14 11:53:19","doi":"10.21203/rs.3.rs-4932918/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-20T16:49:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T01:52:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216304513323264731547738767465339041133","date":"2024-09-07T12:42:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-05T05:24:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-19T13:44:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-19T13:34:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2024-08-18T10:22:16+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":"2bef8a69-23e6-43f6-869f-a9a9cc9f1724","owner":[],"postedDate":"October 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:21:46+00:00","versionOfRecord":{"articleIdentity":"rs-4932918","link":"https://doi.org/10.1007/s00383-024-05908-5","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2024-11-27 15:58:33","publishedOnDateReadable":"November 27th, 2024"},"versionCreatedAt":"2024-10-14 11:53:19","video":"","vorDoi":"10.1007/s00383-024-05908-5","vorDoiUrl":"https://doi.org/10.1007/s00383-024-05908-5","workflowStages":[]},"version":"v1","identity":"rs-4932918","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4932918","identity":"rs-4932918","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}