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www.jssn.org.npJournal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2) 35

Abstract

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journal.

Outcome analysis of Cohen’s cross trigonal ureteric reimplantation 
in paediatric age group
Suman Bikram Adhikari, Ramnandan P Chaudhary, Tul Maya Gurung, Sanjay Sah, Shovita Rana

Department of Paediatric Surgery
Ishan Children and Maternity Hospital, 
Kathmandu, Nepal

Dr Suman Bikram Adhikari, 
Department of Paediatric Surgery
Ishan Children and Maternity Hospital, 
Kathmandu, Nepal

Email- sumanchetri@hotmail.com

None

None

Taken

Introduction: Cohen’s cross trigonal ureteric reimplantation is the 

in children with high success rate. The objective of this study was to 
evaluate and assess the outcome of open Cohen’s procedure in children 

Methods
underwent Cohen’s procedure between March 2010 and February 2020 

Results

minutes for unilateral repair respectively. The mean length of hospital 

abdomen in all patients and micturating cystourethrogram in few patients 

Conclusion: Cohen’s uretric reimplantation is a standard procedure in 

operative technique should be pursued.

Keywords

Original article

cross trigonal ureteric reimplantation in 
pediatric age group. J Sosc Surg Nep. 2022; 



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

Introduction

population.1
remarkable changes in recent years and favors non-

in some instances still needs surgical correction like in 

renal scarring.2-3

In this era of modern technology, laparoscopic ureteric 
re-implantation or endoscopic procedures involving 
subureteric transurethral injection are commonly used for 

quick and minimally invasive and require short hospital 
stay.4 However, in developing countries like Nepal where 

are managed with open ureteric reimplantation. Cohen, in 

and minimal morbidity.

The aim of the current study is to evaluate the outcomes of 
Cohen’s ureteric reimplantation in our part of world. 

Methods
All patients who underwent Cohen’s cross trigonal ureteric 
reimplantation at Ishan Children and Maternity Hospital 

were retrospectively reviewed. Approval for this study was 

time, Clavien- Dindo postoperative complications and 
postoperative follow-up were documented and analyzed. 

Study in Children.  Data were assessed using the hospital 

statistics were performed with the same software.

Inclusion criteria:
• Patients who underwent Cohens uretric reimplantation 

selected.
• Patients who need additional ureteric tapering 

procedures were also included.
• Patients who needed ureteric reimplantation as an 

• Patient who were lost in follow up

Operative technique
All ureteric reimplantations were performed using the 
Cohen cross-trigonal technique. Stents were routinely 
placed. In all patients, the bladder was accessed using 
a Pfannenstiel incision and opened vertically. After 

were dissected and mobilized preserving vessels, nerves 
and vas in male child. A submucosal tunnel was prepared 

anchored to the trigonal muscle and mucosal re-adaption 
was performed using 5/0 polyglactin sutures. In case of 
megaureter, the ureter was tailored or tapered over 12fr 
feeding tube, ureteric stent was kept. Bladder was closed 
in two layers. Abdominal wall was closed in layers using 
absorbable suture. 8-10F retropubic drain tube and foley 
catheter was kept. 

Follow up

along with urine C/S was performed at one month during 

C/S showed no growth.

there is chance of introduction of bacteria to urothelium. 

Results
This study consisted of 40 consecutive patients who 
underwent Cohen’s procedure from March 2010 to 
February 2020. There were 25 girls and 15 boys. Mean 

Table 1

Age at surgery (months) Mean 32 (Range: 6-96)
Sex Male: Female 15 (37.5%): 25(62.5%)
Site of VUR 
(Left:Right:Bilateral)

10:14:16

Operation time One side (minutes) 249.4(200-290)
Operation time both sides (min-
utes)

158.3(130-180)

Hospital stay (days) Mean 10.55 (7-15)
Follow-up (months) Mean 28.13 (7-72)

Table 1. Patient characteristics

Adhikari SB et al



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

Figure 1

bladder diverticulum in close vicinity to ureteric opening] 
Figure 2

Figure 3

Perioperative complications

Table 2

bladder was re-opened and intravesical clot was removed 
and haemostasis secured. Another patient developed 
Hospital Acquired Pneumonia in postoperative period for 

Figure 1. Indication for Cohens ureteric reimplantation 
(N=40)

Figure 2. VUR vs Non-VUR (N=40)

Complications N (%)

Clavien-Dindo grade I 4 (10%)
Clavien-Dindo grade II 6 (15%)
Clavien-Dindo grade III 2 (5%)
Clavien-Dindo grade IV 1 (2.5%)

Table 3
had ultrasound of kidney, ureter and bladder at 3 months of 
postoperative period. Among the 24 unilateral procedures, 
01 patient with obstructed megaureter had moderate to 

Discussion 

damage after acute pyelonephritis has been understood 
since the mid-to late 20th century.8 Subsequently, 

ureters swiftly gained popularity and were demonstrated 
9 For high-risk patients with 

reimplantation remains the risk adapted, standard 
treatment.10 The most commonly used technique for 
ureteric reimplantation with less complications in children 
is Cohen’s cross-trigonal reimplantation.9,11,12

Table 2. Complications/follow-up

Complications N (%)
Febrile UTI 4 (10%)
Non-febrile UTI 8 (20%)
Ureteric Obstruction 0 (0%)
Recurrent VUR 2 (5%)
Re-do surgery later 1 (2.5%)

Table 3. Late complications during follow up



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
38

length which was created in the initial phase of practice. 

tunnel length to- ureteric diameter ratio of up to 1:4-5 
was assumed.  Therefore, tunnel length was measured 
arbitrarily in our patients to maintain the aforementioned 

created by the cross trigonal transfer of the ureter or due to 

The current study was limited by the retrospective nature 
of the design. Additionally, there were fewer numbers of 
reimplantated ureters as this is private children hospital. 

cases for open reimplantation. Finally, the median follow-
up time reported was suboptimal for clinical outcome.

Conclusion
Cohen’s ureteric reimplantation is a standard procedure in 

pursued. 

References

1. 

injection technique for endoscopic treatment 

2. 

performed as an outpatient therapy. Journal of 

3. 
reimplantation: a minimally invasive technique for 

4. Chertin B, Kocherov S, Chertin L, Natsheh A, Farkas 

5. 

There have been many reports on Cohen’s repair with 

technique, the current institution has had two postoperative 

13 and Haid et al14. These 
two complications were encountered in the early phase of 
practice.

stone formation12,15 make it less popular among some 
urologist. None of patients in our study had obstructive 
hydronephrosis and stone formation. 

 grade II 
complications are more likely to occur after a Cohen’s 

the form of reactionary haemorrhage for which reoperation 

associated hospital acquired pneumonia.

challenging, thus creating risk factors of lower success rates, 
were also present. The length of the submucosal tunnel and 
its relation to the diameter of the ureter is reported to be 
an important factor in successful ureteric reimplantation. 

Chung JM, Park CS, Lee SD. Postoperative 
ureteric obstruction after endoscopic treatment for 

JM, Tamminen-Möbius TE. International system 

8. 

9. Cohen SJ. The Cohen reimplantation technique. 

10. 

urology. https://uroweb.org/guideline/paediatric-
urology/#3_13.

11. Mure PY, Mouriquand PD. Surgical atlas the Cohen 

12. 

Adhikari SB et al



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np
39

13. 

intravesical detrusorrhaphy. J Pediatr Surg. 
2013;48:1813e8. 

14. Haid B, Strasser C, Becker T, Koen M, Berger 

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