0022-5347/00/1636-1908/0
®
THE JOURNAL OF UROLOGY
Vol. 163, 1908–1912, June 2000
Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Printed in U.S.A.
THE APPENDIX AS RIGHT URETERAL SUBSTITUTE IN CHILDREN
FRANK RICHTER, JEFFREY A. STOCK AND MONEER K. HANNA
From the Section of Urology, University of Medicine and Dentistry-New Jersey Medical School, Newark, Childrens Hospital of New
Jersey-St. Barnabas Medical Center, Livingston, New Jersey, and New York Hospital-Cornell Medical Center, New York, New York
ABSTRACT
Purpose: The appendix has occasionally been used to replace sections of the right ureter. We
reviewed the literature of the last 25 years on the use of the appendix as right ureteral
replacement and report our experience with right ureteral substitution using the appendix.
Materials and Methods: We retrospectively reviewed the charts of 3 children who underwent
appendiceal replacement of the right ureter. The appendix replaced the upper third of the ureter
and the lower ureter in 1 and 2 cases, respectively.
Results: Followups of 4, 7 and 15 years, respectively, demonstrated that the appendix trans-
ports urine satisfactorily and permits renal function to be maintained with no evidence of
obstruction.
Conclusions: We believe that our small series supports the use of the appendix as a right
ureteral substitute in select cases.
KEY WORDS: ureter, appendix, graft
In 1912 Melnikoff initially reported substitution of the ureteral segment was then resected. The ureteral cut edges
ureter by the vermiform appendix1 but the procedure did not were spatulated and the cecal end of the appendix was anas-
gain wide popularity. Others have replaced part of the right
ureter with appendix2–11 but the majority of cases involved
traumatic ureteral injury.2, 4, 5 We reviewed 9 studies in the
literature of the last 25 years in which the appendix was used
for ureteral replacement (see table).2–10 However, only 2
articles describe appendiceal interposition in children.
Mesrobian and Azizkhan reported on a 7-year-old girl with
ureteral necrosis due to dermatomyositis.6 Martin replaced
the right ureter with appendix in an 8-year-old boy with right
ureteral stricture due to posterior urethral valves.9 In the
majority of reported cases information on long-term followup
is not available.1–12 We report on 3 children who underwent
ureteral replacement with appendix and followup is 4, 7 and
15 years, respectively.
tomosed to the renal pelvis. Tension-free anastomosis was
created with interrupted sutures and a Double-J stent
was placed over a guide wire from the renal pelvis into the
bladder.
Retrograde pyelography 6 months postoperatively showed
a patent appendiceal lumen (fig. 1, B). A 6Fr ureteral cath-
eter was easily advanced through the suture lines into the
right renal pelvis. The patient was followed with ultrasonog-
raphy for 7 years. He was symptom-free at last followup in
1998.
Case 2. V. G., a 13-year-old girl, was referred for urinary
reconstruction. Previous ureteral reimplantation of a solitary
ureter and kidney during early childhood had been unsuc-
cessful. Subsequently right end ureterostomy was performed
elsewhere. She inquired about urinary undiversion and was
referred to us in 1980 (fig. 3, A).
CASE HISTORIES
After surgical exploration the appendix was evaluated.
Length and vascular supply were considered suitable to con-
nect the mid ureter to the bladder in a tension-free manner.
The appendicular artery was preserved and the appendix
transected, leaving a cuff of cecal wall. The dilated mid ureter
was then mobilized, tapered and anastomosed to the cecal
end of the appendix in an isoperistaltic fashion. The bladder
was mobilized and a psoas hitch was used. The distal end of
the appendix was then reimplanted into a 3 cm. submucosal
tunnel in the bladder (fig. 4).
Followup voiding cystourethrography 6 months postopera-
tively confirmed absent reflux (fig. 3, B). Excretory urogra-
phy (IVP) revealed a patent appendiceal interposition with a
mild degree of hydronephrosis and ureteral dilatation (fig. 3,
C). The patient was symptom-free with stable renal function
at last followup in 1995.
Case 1. E. K., a 19-year-old male, was born with bilateral
ureteropelvic junction obstruction and underwent left pyelo-
plasty at age 4.5 years. At age 5 years right pyeloplasty was
performed elsewhere. This procedure was repeated at age 14
years and spiral flap pyeloplasty was done at age 17 years.
Stricture of the upper right ureter was treated with 2 endo-
pyelotomies as well as balloon dilation and a Double-J* stent.
The patient was referred to us because of recurrent episodes
of right flank pain and worsening right hydronephrosis (fig.
1, A). In addition to using appendix, we also considered renal
autotransplantation and replacement of the ureter with
ileum.
Figure 2 shows the procedure. A midline incision was made
from the mid epigastrium to the symphysis pubis. Generous
exposure allowed access to the whole ureter as well as expo-
sure of the appendix. A 5 cm. segment of obstructed proximal
ureter was surrounded by fibrotic retroperitoneal tissue. Due
to the length of the diseased segment direct end-to-end anas-
tomosis was not possible. Therefore, we evaluated the length,
Case 3. S. P, an 11-year-old female, was born with neurogenic
bladder due to myelomeningocele. At age 5 years urinary diver-
sion into a colon conduit was performed elsewhere (fig. 5, A).
mobility and vascular supply of the appendix. The 2 appen- She was referred to us for possible undiversion 6 years later in
dicular arteries were preserved, and the right colon and 1981. Urodynamic evaluation revealed good bladder capacity
cecum were mobilized. The appendix was transected across
the base of the cecum using a TA-30 stapler. The scarred
Accepted for publication January 7, 2000.
* Medical Engineering Corp., New York, New York.
and compliance. The patient easily learned intermittent cathe-
terization. Bladder cycling demonstrated dryness with 350 ml.
of water in the defunctionalized bladder.
Laparotomy was done via a midline incision. The ureters
1908
Traube,W.
