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Mele E, Ghidini F, Contini G, Capozza N, Castagnetti M. Risk Factors for Failure of Endoscopic Balloon Dilatation of Primary Obstructive Megaureter: Single-Center 12-Year Experience with 123 Cases. J Endourol 2024; 38:480-487. [PMID: 38450567 DOI: 10.1089/end.2023.0550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Purpose: To review our experience with >100 patients with primary obstructive megaureter (POM) undergoing endoscopic balloon dilatation (EBD) and a follow-up of up to 12 years and determine potential risk factors for failure. Our hypothesis is that EBD allows for long-term treatment in >80% of patients, and its effectiveness decreases in more severe cases. Methods: This is a retrospective study of 123 consecutive patients (131 ureters) undergoing EBD from 2009 to 2021. Indications for EBD included symptoms, worsening dilatation, and/or renal function impairment. Clinical characteristics, complications, and outcomes, including those in the patients with >5-year follow-up, were described. Preoperative and intraoperative markers of severity chosen a priori were tested as risk factors for failure. Failure was defined as the need for ureteral reimplantation after EBD. Results: EBD was feasible in 121 of 123 (98%) patients, regardless of age. After a median follow-up of 38 (9-143) months, EBD was effective in 84.5% of cases. Failures generally occurred in the 1st year after EBD and were seldom associated with permanent loss of renal function. Of the 66 patients with follow-up >5 years, EBD was effective in 56 patients. No preoperative characteristic proved to be a risk factor for failure. The intraoperative absence of a ring was the only significant risk factor for failure, odd ratio 117.86 (95% confidence interval 6.27-2215.84). Conclusions: EBD was feasible and definitive treatment in 85% of our cases, regardless of age. Since this study did not identify preoperative factors to help the clinicians in patient selection, we consider EBD a viable initial procedure in all patients with POM who require surgical intervention, especially in infants.
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Affiliation(s)
- Ermelinda Mele
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Filippo Ghidini
- Pediatric Surgery Unit, Department of Child Health, University Hospital of Modena, Modena, Italy
| | - Giorgia Contini
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Nicola Capozza
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Padua, Italy
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Isac GV, Danila GM, Ionescu SN. Spontaneous resolution and the role of endoscopic surgery in the treatment of primary obstructive megaureter: a review of the literature. LA PEDIATRIA MEDICA E CHIRURGICA 2023; 45. [PMID: 38112615 DOI: 10.4081/pmc.2023.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
The megaureter accounts for almost a quarter of all urinary tract dilations diagnosed in utero and is the second leading cause of hydronephrosis in newborns, following pyeloureteral junction obstruction. The current standard treatment for progressive or persistent, symptomatic primary obstructive megaureter is ureteral anti-reflux reimplantation, which can be associated with ureteral remodeling or plication. Due to the associated morbidity, postoperative recovery challenges, and the complications that may arise from the open surgical approach, there has been a natural inclination towards validating new minimally invasive techniques. This study reviews the literature, extracting data from three major international databases, from 1998 to 2022. Out of 1172 initially identified articles, only 52 were deemed eligible, analyzing 1764 patients and 1981 renal units. Results show that 65% of cases required surgical intervention, with minimally invasive techniques constituting 56% of these procedures. High-pressure endoscopic balloon dilation was the preferred endourologic technique. The degree of ureterohydronephrosis is considered one of the factors indicating the need for surgery. There is an inverse relationship between the diameter of the ureter and the likelihood of spontaneous resolution. Conditions such as renal hypoplasia, renal dysplasia, or ectopic ureteral insertion strongly indicate a poor prognosis. Endoscopic surgical techniques for treating primary obstructive megaureter can be definitive, firstline treatment options. In selected cases, they might be at least as effective and safe as the open approach, but with advantages like quicker recovery, fewer complications, shorter hospital stays, and reduced costs.
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Affiliation(s)
| | - Gabriela Mariana Danila
- Department of Pediatric Surgery and Urology, Maria Sklodowska Curie Emergency Children Hospital, Bucharest.
| | - Sebastian Nicolae Ionescu
- Department of Pediatric Surgery and Urology, Maria Sklodowska Curie Emergency Children Hospital, Bucharest.
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Ortiz R, Burgos L, Fernández-Bautista B, Parente A, Ordóñez J, Angulo JM. Endoscopic balloon dilation of primary obstructive megaureter: is fluoroscopic guidance necessary? World J Urol 2023; 41:2861-2867. [PMID: 37690062 DOI: 10.1007/s00345-023-04572-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE To compare the long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation under fluoroscopic guidance versus not using radioscopy during the procedure. PATIENTS AND METHODS A comparative study between POM cases treated at our institution by endoscopic balloon dilation (EBD) under fluoroscopic guidance (FG) (n = 43) vs no fluoroscopic guidance (NFG) (n = 48) between the years 2004 and 2018 was conducted. The procedure in FG consisted of performing a retrograde pyelography before dilation. Then, a guidewire is introduced to the renal pelvis, and the dilation of the vesicoureteral junction is performed using high-pressure balloon catheters under fluoroscopic vision. Finally, a double-J stent is placed between the renal pelvis and bladder. The procedure in NFG was performed exclusively under cystoscopic vision without radiological exposure. Complications, outcomes, and success rates were analyzed using Spearman's correlation test. Mean follow-up was 12.5 ± 2.2 years in FG and 6.4 ± 1.3 years in NFG. RESULTS MAG-3 showed significant differences in renal drainage before and after endoscopic treatment in both groups (p < 0.001 T-test). Statistical analysis did not reveal differences between groups in initial technical failure (r: - 0.035, p = 0.74), early postoperative complications (r: - 0.029, p = 0.79), secondary VUR (r: 0.033, p = 0.76), re-stenosis (r: 0.022, p = 0.84), long-term ureteral reimplantation (r: 0.065, p = 0.55), and final outcome (r: - 0.054, p = 0.61). The endoscopic approach of POM had a long-term success rate of 86.5% in FG VS 89.6% in NFG. CONCLUSIONS Endoscopic balloon dilation of POM can be done with no radiation exposure with similar results, effectiveness, and outcomes.
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Affiliation(s)
- Rubén Ortiz
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Laura Burgos
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Beatriz Fernández-Bautista
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Parente
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Ordóñez
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Jose María Angulo
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
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High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review. BMC Urol 2023; 23:30. [PMID: 36869342 PMCID: PMC9985206 DOI: 10.1186/s12894-023-01199-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVE We aimed to evaluate the effectiveness and complication rates of endoscopic high-pressure balloon dilatation (HPBD) in treating primary obstructive megaureter (POM) in children based on current literature. Specifically, we wanted to clarify the evidence on the use of HPBD in children under one year of age. METHODS A systematic search of the literature was performed via several databases. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. The primary outcomes studied in this systematic review were the effectiveness of HBPD in relieving obstruction and reducing hydroureteronephrosis in children. The secondary outcome was to study the complication rate of endoscopic high-pressure balloon dilatation. Studies that reported one or both of these outcomes (n = 13) were considered eligible for inclusion in this review. RESULTS HPBD significantly decreased both ureteral diameter (15.8 mm [range 2-30] to 8.0 mm [0-30], p = 0.00009) and anteroposterior diameter of renal pelvis (16.7 mm [0-46] to 9.7 mm [0-36], p = 0.00107). The success rate was 71% after one HPBD and 79% after two HPBD. The median follow-up time was 3.6 years (interquartile range 2.2-6.4 years). A complication rate of 33% was observed, but no Clavien-Dindo grade IV-V complications were reported. Postoperative infections and VUR were detected in 12% and 7.8% of cases, respectively. For children under one year of age, outcomes of HPBD seem to be similar to those in older children. CONCLUSIONS This study indicates that HPBD appears to be safe and can be used as the first-line treatment for symptomatic POM. Further comparative studies are needed addressing the effect of treatment in infants, and also long-term outcomes of the treatment. Due to the nature of POM, identifying those patients who will benefit from HPBD remains challenging.
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Contini G, Mele E, Capozza N, Castagnetti M. Endoscopic balloon dilatation for the treatment of primary obstructive megaureter <24 months of age: Does the size of the balloon influence results? J Pediatr Urol 2022; 19:198.e1-198.e9. [PMID: 36494270 DOI: 10.1016/j.jpurol.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Endoscopic balloon dilatation (EBD) can be performed with different catheters and its durability is still controversial. This study aimed to compare long-term results of EBD performed <24 months of age using balloons of 4 mm vs. 6 mm in diameter. MATERIALS AND METHODS Retrospective study of consecutive patients with unilateral primary obstructive megaureter (POM) undergoing EBD <24 months of age by two surgeons from 01/2009 to 12/2020. The technique was consistent, but for balloon diameter, which was 4 mm in group A vs. 6 mm in group B. End-points included peri-operative complications, success rate (improving dilatation and non-obstructive drainage on 9-month scintigraphy), and long-term outcome (need for reimplantation and diameter of retrovesical ureter at last ultrasound). RESULTS The procedure was completed in all planned patient. Group A included 15 patients and Group B 30 patients. Groups were not significantly different for age (p < 0.09), gender (p < 0.1), laterality (p < 0.7), and preoperative median ureteral diameter (p = 0.08). No perioperative complications occurred. Four group A patients required a cutting balloon to achieve a satisfactory dilatation of the vesicoureteral junction (p = 0.009). After a median (range) follow-up of 70 (19-155) months, success rate was 73.3% vs. 83.3% (p = 0.45), 4/15 group A and 5/30 group B patients required reimplantation within 2 years of EBD. In successful cases, median (range) ureteral diameter at last follow-up was 6 (0-17) mm vs. 5 (0-14) mm, which was significantly better than preoperative value (p = 0.003 and p < 0.001, respectively), but not significantly different (p = 0.8) between groups. DISCUSSION EBD is an umbrella term that encompasses many technical variations, which can be key for success. Although limited by the small numbers and the comparison of patients treated over two subsequent periods, this is the first study focusing on the role of balloon size. CONCLUSIONS The diameter of the balloon did not influence significantly long-term results, but the 6 mm balloon slightly increased the success rate of EBD to 83.3% and eliminated the need for cutting balloons to achieve a satisfactory dilatation.
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Affiliation(s)
- Giorgia Contini
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Ermelinda Mele
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Nicola Capozza
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy; Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy.
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Postoperative JJ stent is not necessary after balloon high-pressure endoscopic dilatation of primary obstructive megaureter. J Pediatr Urol 2022; 18:369.e1-369.e7. [PMID: 35562267 DOI: 10.1016/j.jpurol.2022.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/01/2022] [Accepted: 03/31/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION A wide range of surgical interventions have been described for the management of primary obstructive megaureter (POM). Endoscopic balloon dilatation has been developed through last decades as a minimally invasive alternative to classic surgery. OBJECTIVE To assess the need for placement of a double J stent after endoscopic balloon dilatation procedure, by comparing the post-operative related outcomes with and without double J placement. Secondary outcome was the success rate, considering the need for further procedure after endoscopic balloon dilatation and the improvement of the ureteral diameter in the two groups. STUDY DESIGN Historical retrospective comparison of children treated by endoscopic dilatation for POM, with post-operative JJ stent left in place (2012-2014) or without ureteral JJ stent (since 2015). Post-operative complications were reported following Clavien-Dindo grading system and compared between the two groups. Success rate was defined as absence of need for further surgical reimplantation. Ureteral diameters on preoperative and postoperative renal ultrasounds were compared. RESULTS Endoscopic dilatations were performed in 42 patients for 46 renal units during the study period. There was a significantly higher rate of post-operative complications in the group with JJ stenting compared to the group without double J stenting regarding all Clavien-Dindo grades (56% vs 15%, p = 0.014) and Clavien-Dindo grade III only (31% vs 0%, p = 0,0051) (Figure). The success rate was similar in the JJ group (75%, F-up: 70 months [13-101]) and the no JJ group (81%, F-up: 26 months [12-95]). There was a significant improvement of US renal pelvis and ureter dilatation in both groups, with a median follow-up of 35.5 months [12-101]. DISCUSSION The overall rate of complications was slightly higher than in other reports and higher in the JJ group regarding Clavien-Dindo grade III complications. The success rate was comparable to previous studies reviewing endoscopic dilatations and equivalent in the two groups. CONCLUSION In our study, the omission of postoperative ureteral drainage by a JJ stent after endoscopic balloon dilatation of POM did not increase post-operative complications rate without demonstrable impact on the success rate.
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Wishahi M, Hafiz E, Wishahy AMK, Badawy M. Telocytes, c-Kit positive cells, Smooth muscles, and collagen in the ureter of pediatric patients with congenital primary obstructive megaureter: elucidation of etiopathology. Ultrastruct Pathol 2021; 45:257-265. [PMID: 34315317 DOI: 10.1080/01913123.2021.1954734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Congenital primary obstructive megaureter (POM) is an uncommon pediatric anomaly that is due to obstructive distal ureter leading to the loss of peristalsis with consequent ureterohydronephrosis causing loss of kidney function. The objectives are to elucidate the etiology of POM by demonstrating the presence of interstitial cells of Cajal (ICC), telocytes, smooth muscles, and collage in the obstructive and dilated ureteral segments. The study was carried out on 15 surgical specimens of congenital POM in pediatric patients, age range was 4 to 24 months, they were operated upon by excision of the obstructed segment, tailoring the dilated ureter, and anastomosing it to the bladder. Specimens included the obstructed ureteral segment and part of the dilated ureter. Specimens were examined with hematoxylin and eosin (H&E) stain, Modified Gomori trichrome stain, immunohistochemistry (IHC) with α-muscle actin, and c-kit (CD117), and transmission electron microscopy (TEM). Obstructed segment showed excess collagen intervening between smooth muscles, excess c-Kit positive cells, and presence of telocytes. The dilated segment of the ureteral wall is formed of smooth muscle bundles with scanty collagen. Staining with c-Kit did not demonstrate positive cells. TEM showed myofibroblasts and close adherence of smooth muscle cells to each other with absence of telocytes. The pathophysiology of POM is multifactorial. Loss of interstitial cells and rarity of collagen result in loss of elasticity of dilated segment leading to massive dilatation. While the obstructed segment had no muscle conductivity due to excess collagen irrespective of presence of telocytes.
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Affiliation(s)
- Mohamed Wishahi
- Department of Urology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ehab Hafiz
- Clinical Laboratory Department, Electron Microscopy Laboratory, Theodor Bilharz Research Institute, Cairo, Egypt
| | - A M K Wishahy
- Department of Pediatric Surgery- Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Badawy
- Department of Urology, Theodor Bilharz Research Institute, Cairo, Egypt
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Destro F, Selvaggio G, Marinoni F, Pansini A, Riccipetitoni G. High-pressure balloon dilatation in children: our results in 30 patients with POM and the implications of the cystoscopic evaluation. LA PEDIATRIA MEDICA E CHIRURGICA 2020; 42. [PMID: 33029994 DOI: 10.4081/pmc.2020.214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 02/18/2020] [Indexed: 11/23/2022] Open
Abstract
Primary Obstructive Megaureter (POM) is a common cause of hydronephrosis in children with spontaneous resolution in most cases. High-Pressure Balloon Dilatation (HPBD) has been proposed as a minimally invasive procedure for POM correction in selected patients. The aim of the paper is to review our experience with HPBD in patients with POM. We performed a retrospective study in a single Centre collecting data on patients' demographics, diagnostic modalities, surgical details, results and follow-up. In particular, the endoscopic aspect of the orifice permitted the identification of 3 patterns: adynamic ureteral segment, stenotic ureteric ring and pseudoureterocelic orifice. We performed HPBD in 30 patients over 6 years. We had 23 patients with adynamic distal ureteral segment (type 1), 4 with stenotic ring (type 2) and 3 with ureterocelic orifice (type 3). In 3 patients (10%) the guidewire did not easily pass into the ureter requiring ureteral stenting or papillotomy. Post-operative course was uneventful. Five patients (3 pseudoureterocelic) required open surgery during follow-up. HPBD for the treatment of POM is a safe and feasible procedure and it can be a definitive treatment of POM. Complications are mainly due to double J stent and none of our patients had symptoms related to vescico-ureteral reflux. The aspect of the orifice, identified during cystoscopy, seems to correlate with the efficacy of the dilatation: type 1 and 2 are associated with good and excellent results respectively; type 3 do not permit dilatation in almost all cases requiring papillotomy. HPBD can be performed in selected patients of all paediatric ages as first therapeutic line. The presence of a pseudoureterocelic orifice or long stenosis might interfere with the ureteral stenting and seems associated with worse outcomes.
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Affiliation(s)
- Francesca Destro
- Paediatric Surgery and Paediatric Urology Department, Buzzi Children's Hospital, Milan.
| | - Giorgio Selvaggio
- Paediatric Surgery and Paediatric Urology Department, Buzzi Children's Hospital, Milan.
| | - Federica Marinoni
- Paediatric Surgery and Paediatric Urology Department, Buzzi Children's Hospital, Milan.
| | - Andrea Pansini
- Paediatric Surgery and Paediatric Urology Department, Buzzi Children's Hospital, Milan.
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Lopez M, Perez-Etchepare E, Bustangi N, Godik O, Juricic M, Varlet F, Gutierrez R, Gomez Culebras M, Gander R, Royo G, Asensio M. Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter. J Laparoendosc Adv Surg Tech A 2020. [PMID: 32212997 DOI: 10.1089/lap.2019.0396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.
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Affiliation(s)
- Manuel Lopez
- Department of Pediatric Surgery & Urology, University Hospital of Vall d'Hebron, Barcelona, Spain.,Department of Pediatric Surgery & Urology, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Eduardo Perez-Etchepare
- Department of Pediatric Surgery & Urology, University Hospital Nuestra Senora de Candelaria, Tenerife, Spain
| | - Nasser Bustangi
- Department of Pediatric Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Oleg Godik
- Department of Pediatric Surgery & Urology, National Medical University and Clinic Oberig, Kiev, Ukraine
| | - Michel Juricic
- Service de Chirurgie Pédiatrique et Urologie Toulouse, Clinique Rive du Gauche, Toulouse, France
| | - Francois Varlet
- Department of Pediatric Surgery, University Hospital of Saint Etienne, Saint Etienne, France
| | - Rocio Gutierrez
- Department of Pediatric Surgery, University Hospital of Arnaud de Villanova, Lleida, Spain
| | - Mario Gomez Culebras
- Department of Pediatric Surgery & Urology, University Hospital Nuestra Senora de Candelaria, Tenerife, Spain
| | - Romy Gander
- Department of Pediatric Surgery & Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Gloria Royo
- Department of Pediatric Surgery & Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Marino Asensio
- Department of Pediatric Surgery & Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
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Romero RM. Management of Primary Obstructive Megaureter by Endoscopic High-Pressure Balloon Dilatation. IDEAL Framework Model as a New Tool for Systematic Review. Front Surg 2019; 6:20. [PMID: 31058164 PMCID: PMC6478015 DOI: 10.3389/fsurg.2019.00020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Therapeutic management of primary obstructive megaureter (POM) requiring surgery has been under debate for the last 15 years especially regarding the outcomes of endoscopic techniques compared to most traditional approaches. This review aims to analyze endoscopic High-Pressure Balloon Dilatation (HPBD) using the IDEAL model, a five-stage framework that describes surgical innovations (Idea, Development, Exploration, Assessment, and Long-term Study) and provides recommendations for a rigorous stepwise surgical research pathway. This model has been developed and demonstrated its value in evaluating surgical innovations assessing data quality and providing relevant information for the optimal design and feasibility of research in surgery. Materials and Methods: A systematic review of the published series of endoscopic HPBD in patients with POM was done using the IDEAL model as a tool to assess evidence quality. Reported clinical outcomes are also analyzed and reviewed. Results: The analysis of the results of the systematic assessment of the reported cohort of patients treated with HPBD for POM that the technique up to date is in stage 2a and stage 2b, or development. Evidence quality among the reported cohorts of patients with POM treated with HPBD is adequate, although systematization and standardization should be improved. Clinical outcomes of HPBD in the management of POM consistently show a 87.7% success rate with a negligible operative complication rate once "learning curve" has been surpassed. Symptomatic vesicoureteral reflux (VUR) is the main reason for ureteric reimplantation, but asymptomatic VUR does not seem to influence clinical outcome. Conclusions: The IDEAL framework and recommendations have allowed a systematic analysis of the evidence quality of the reported experience in the management of children with POM with HPBD of the vesicoureteral junction. The available evidence demonstrates that HPBD is an effective treatment for patients with POM, with a long-term success rate of 87.7% with very low morbidity. Future research mandates a standardization of data reporting, "ideally" following IDEAL recommendations, that would be required for any intervention and facilitate comparative analysis.
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Affiliation(s)
- Rosa M Romero
- Pediatric Urology Unit, Hospital Universitario Virgen del Rocío, Seville, Spain
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Doudt AD, Pusateri CR, Christman MS. Endoscopic Management of Primary Obstructive Megaureter: A Systematic Review. J Endourol 2018; 32:482-487. [PMID: 29676162 DOI: 10.1089/end.2017.0434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The gold standard treatment for primary obstructive megaureter (POM) with declining renal function, worsening obstruction, or recurrent infections is ureteral reimplantation with or without tapering. In infants, open surgery can be technically demanding and associated with significant morbidity. We conducted a systematic review of the literature with special interest in endoscopic management of POM and its outcomes. MATERIALS AND METHODS A search was conducted of the MEDLINE/Ovid, PubMed, Embase, and Web of Science databases. Only full-text articles written in the English language and involving greater than one reported pediatric case per publication were included. Two authors independently extracted data and assessed strength of evidence for each study. RESULTS We found 11 retrospective and 1 prospective, single institution case series that met selection criteria, describing 222 patients with 237 obstructed renal units. Mean age at time of surgery was 24.6 months. The most common endoscopic approaches were cystoscopy+high-pressure balloon dilation+Double-J ureteral stent placement (49.5%), cystoscopy+incisional ureterotomy+Double-J ureteral stent placement (27.8%), and cystoscopy+Double-J ureteral stent placement (18.9%). For all approaches and age groups, anatomic and functional success rates were 79.3% (146/184) and 76.7% (132/172), respectively. Anatomic success rates were highest in children ≥12 months of age (82.3%, 117/142). Endoscopic retreatment was performed in 15.1% of cases with a 36.7% overall surgical reintervention rate. Forty-one ureters progressed to ureteral reimplantation. Complications were generally mild (Clavien-Dindo Grades I-II), but 12 ureters did develop vesicoureteral reflux. Mean follow-up period was 3.2 years. CONCLUSIONS Endoscopic management for persistent or progressive POM in children ≥12 months of age is a minimally invasive alternative to ureteral reimplantation with modest success rates. In infants, it may best be utilized as a temporizing procedure. Approximately one-third of patients require surgical reintervention.
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Affiliation(s)
- Alexander D Doudt
- Department of Urology, Naval Medical Center San Diego , San Diego, California
| | - Chad R Pusateri
- Department of Urology, Naval Medical Center San Diego , San Diego, California
| | - Matthew S Christman
- Department of Urology, Naval Medical Center San Diego , San Diego, California
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Casal Beloy I, Somoza Argibay I, García González M, García Novoa MA, Míguez Fortes LM, Dargallo Carbonell T. Endoscopic balloon dilatation in primary obstructive megaureter: Long-term results. J Pediatr Urol 2018; 14:167.e1-167.e5. [PMID: 29398584 DOI: 10.1016/j.jpurol.2017.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/20/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open neoureterocystostomy is the traditional surgical treatment for primary obstructive megaureter (POM). Endoscopic balloon dilation is a new minimally invasive alternative. It has been shown to be a safe and effective endoscopic procedure over short-term follow-up; however, few studies have shown its long-term efficacy. OBJECTIVE The aim of this study was to evaluate the long-term results and complications of balloon dilation for the treatment of primary obstructive megaureter in infants. MATERIALS AND METHOD A retrospective review was performed of patients with primary obstructive megaureter treated with balloon dilation. The diagnosis was made through ultrasonography, diuretic isotopic renogram, and voiding cystourethrogram (VCUG). The indications for surgery were: worsening hydronephrosis, renal function impairment, and recurrent urinary tract infections (UTI). All patients were followed 3 months after the endoscopic procedure with ultrasonography and MAG-3 renogram, and 6 months after surgery with VCUG and ultrasonography. Annual ultrasound and clinical follow-up were performed until present time. RESULTS Seven boys and six girls were treated (median age 9 months, range 2-24). Ten patients had a prenatal diagnosis of hydronephrosis, and the diagnoses was made after UTI in three patients. No intraoperative complications were observed. One double-J stent was replaced after endoscopic procedure for malpositioning, and four patients developed UTIs after surgery. All patients had non-obstructive MAG-3 diuretic renogram 6 months after surgery. The mean washout on the renogram and the ultrasound pelvic diameter showed pre-operative and postoperative statistical differences (Summary Table). All patients maintained their results without recurrence or any other complications in the long-term follow-up. The median follow-up was 10.3 years (range 4.7-12.2). DISCUSION In 2014, Aparicio et al. first described balloon dilation being used as a definitive treatment for primary obstructive megaureter in infants. Bujons et al. also presented 20 cases with a mean follow-up of 6.9 years. The current study is the largest to date, with a median follow-up of 10.2 years. It demonstrated the value of balloon dilation as a definitive treatment for POM. Despite these results, it was difficult to establish endoscopic balloon dilation as a definitive treatment for POM, due to the absence of long-term studies like the current one. CONCLUSION Balloon dilation can be a safe and effective endoscopic procedure for the treatment of primary obstructive megaureter in infants, and has shown good outcomes in long-term follow-up. More studies are needed to demonstrate these results.
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Affiliation(s)
- I Casal Beloy
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain.
| | - I Somoza Argibay
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain
| | - M García González
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain
| | - M A García Novoa
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain
| | - L M Míguez Fortes
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain
| | - T Dargallo Carbonell
- Department of Pediatric Surgery, Pediatric Urology Division, University Children's Hospital of A Coruña, As Xubias, 84, A Coruña, Spain
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Ortiz R, Parente A, Perez-Egido L, Burgos L, Angulo JM. Long-Term Outcomes in Primary Obstructive Megaureter Treated by Endoscopic Balloon Dilation. Experience After 100 Cases. Front Pediatr 2018; 6:275. [PMID: 30345263 PMCID: PMC6182095 DOI: 10.3389/fped.2018.00275] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/12/2018] [Indexed: 11/13/2022] Open
Abstract
Aim: To assess long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation (EBD) in the largest series reported. Patients and Methods: Hundred POM in 92 consecutive patients were treated by EBD between years 2004 and 2016. A total of 79 POM (73 patients) with more than 18 months of follow-up after treatment have been analyzed. EBD of the vesicoureteral junction was performed with semicompliant high-pressure balloon catheters (2.7FG) with minimum balloon diameter of 5 mm, followed by temporary Double-J stent placement. Follow-up protocol included periodical clinical reviews, US and MAG-3 renogram scans. Results: Median age at surgery was 4 months (15 days-3.6 years), with median operating time of 20 min (10-60) and hospital stay of 1 day (1-7). Initial renal function was preserved in all patients with significant improvement in renal drainage on the MAG-3 diuretic renogram after endoscopic treatment (p < 0.001 T-test). Significant post-operative differences were observed in hydronephrosis grade and ureteral diameter that were maintained in the long-term (p < 0.001 T-test). Endoscopic approach of POM had a long-term success rate of 87.3%, with a mean follow-up of 6.4 ± 3.8 years. Secondary VUR was found in 17 cases (21.5%), being successfully treated by endoscopic subureteral injection in 13 (76.4%). Nine cases developed long-term re-stenosis (12.2%) that were successfully treated with a new EBD in 8. Endoscopic management of POM failed in 10 cases (12.7%) that required ureteral reimplantation. Five were early failures (4 intraoperative technical problems and 1 double-J stent migration with severe re-stenosis), and 5 long-term (4 persistent VUR and 1 re-stenosis recurrence). Conclusion: EBD has shown to be an effective treatment of POM with few complications and good outcomes at long-term follow up. Main complication was secondary VUR that could also be treated endoscopically with a high success rate. In our opinion, EBD may be considered first-line treatment in POM.
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Affiliation(s)
- Ruben Ortiz
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Parente
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Perez-Egido
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Burgos
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Maria Angulo
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Kassite I, Renaux Petel M, Chaussy Y, Eyssartier E, Alzahrani K, Sczwarc C, Villemagne T, Lardy H, Braik K, Binet A. High Pressure Balloon Dilatation of Primary Obstructive Megaureter in Children: A Multicenter Study. Front Pediatr 2018; 6:329. [PMID: 30430104 PMCID: PMC6220115 DOI: 10.3389/fped.2018.00329] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/15/2018] [Indexed: 11/27/2022] Open
Abstract
Aim of the Study: We described the initial experience of four referral centers in the treatment of primary obstructive megaureter (POM) in children, by high-pressure balloon dilatation (HPBD) of the ureterovesical junction with double JJ stenting. We managed a retrospective multicenter study to assess its effectiveness in long-term. Methods: We reviewed the medical records of all children who underwent HPBD for POM that require surgical treatment from May 2012 to December 2017 in four different institutions. The primary outcome measured was ureterohydronephrosis (UHN) and its degree of improvement after the procedure. Secondary outcomes were postoperative complications and resolution of preoperative symptomatology. Main Results: Forty-two ureters underwent HPBD for POM in 33 children, with a median age of 14.7 months - (range: 3 months -15 years). Ureterohydronephrosis improves in 86% of ureters after one endoscopic treatment. Three cases required a second HPBD. Four patients required surgical treatment for worsening of UHN after endoscopic treatment. The post-operative complication rate was 50% (21 ureters). In 13 cases (61%), they were related to double J stent. The median follow-up was 24 months (2 months -5 years) and all patients were symptom-free. Conclusion: We reported the first multicenter study and the largest series of children treated with HPBD, with an overall success rate of 92%. Endoscopic treatment can be a definitive treatment of POM since it avoided reimplantation in 90% of cases. Complications are mainly due to double J stent.
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Affiliation(s)
- Ibtissam Kassite
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Mariette Renaux Petel
- Department of Pediatric Surgery, University Teaching Hospital of Rouen, Charles Nicolle Hospital, Rouen, France
| | - Yann Chaussy
- Department of Pediatric Surgery, University Teaching Hospital of Besançon, Jean Minjoz Hospital, Besancon, France
| | - Emilie Eyssartier
- Department of Pediatric Surgery, University Teaching Hospital of Angers, Angers, France
| | - Khalid Alzahrani
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Caroline Sczwarc
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Thierry Villemagne
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Hubert Lardy
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Karim Braik
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
| | - Aurélien Binet
- Department of Pediatric Surgery, University Teaching Hospital of Tours, Gatien de Clocheville Hospital, Tours, France
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Alyami FA, Koyle MA, Bowlin PR, Gleason JM, Braga LH, Lorenzo AJ. Side-to-Side Refluxing Nondismembered Ureterocystotomy: A Novel Strategy to Address Obstructed Megaureters in Children. J Urol 2017; 198:1159-1167. [DOI: 10.1016/j.juro.2017.05.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Fahad A. Alyami
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Martin A. Koyle
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Paul R. Bowlin
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Urology, University of Kansas Medical Center and Children’s Mercy Hospital, Kansas City, Kansas
| | - Joseph M. Gleason
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Urology, University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, Memphis, Tennessee
| | - Luis H. Braga
- Division of Urology, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Armando J. Lorenzo
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lopez M, Gander R, Royo G, Varlet F, Asensio M. Laparoscopic-Assisted Extravesical Ureteral Reimplantation and Extracorporeal Ureteral Tapering Repair for Primary Obstructive Megaureter in Children. J Laparoendosc Adv Surg Tech A 2017; 27:851-857. [DOI: 10.1089/lap.2016.0456] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Manuel Lopez
- Department of Pediatric Surgery and Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Romy Gander
- Department of Pediatric Surgery and Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Gloria Royo
- Department of Pediatric Surgery and Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - François Varlet
- Department of Pediatric Surgery and Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
| | - Marino Asensio
- Department of Pediatric Surgery and Urology, University Hospital of Vall d'Hebron, Barcelona, Spain
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Khan A, Rahiman M, Verma A, Bhargava R. Novel technique of laparoscopic extravesical ureteric reimplantation in primary obstructive megaureter. Urol Ann 2017; 9:150-152. [PMID: 28479766 PMCID: PMC5405658 DOI: 10.4103/0974-7796.204182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective: This study aims to demonstrate a novel laparoscopic technique of tapering megaureter without disrupting the blood supply and disconnecting the ureter. Materials and Methods: Eight cases of primary obstructive megaureter in the age group of 14–22 years underwent laparoscopic extravesical ureteric reimplantation between August 2011 and July 2015 using our novel technique. Five patients had obstruction on left side and three on right side. Follow-up ultrasonography at 1 month and 3 months, voiding cystourethrogram (VCUG) at 3 months and intravenous urogram (IVU) at 6 months was obtained to assess the development of reflux and to look for adequate drainage of the obstructive ureter. Results: Average age of the patients at the time of surgery was 18.5 years. Mean operating time was 95 min. Mean blood loss of 20 ml. VCUG done after 3 months showed no reflux in all cases. IVU done after six months showed no obstruction and complete drainage of dye. Conclusion: Our technique of tapering obstructed megaureter over a preplaced ureteral dilator is time saving and also helps in preserving blood supply to lower ureter. As a result, ureteric anastomotic stricture rate is very low. It is easily reproducible in the open as well as by robotic.
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Affiliation(s)
- Altaf Khan
- Department of Urology, Yenepoya Medical College, Mangalore, Karnataka, India
| | - Mujeebu Rahiman
- Department of Urology, Yenepoya Medical College, Mangalore, Karnataka, India
| | - Ashish Verma
- Department of Urology, Yenepoya Medical College, Mangalore, Karnataka, India
| | - Rahul Bhargava
- Department of Urology, Yenepoya Medical College, Mangalore, Karnataka, India
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Schäfer M, Stehr M. Hydronephrose und Blasenentleerungsstörung. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0164-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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