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Li Z, Yang K, Du Y, Li X, Li Z, Wang B, Huang C, Chen S, Zhang Y, Zhu H, Zhang P, Zhou L, Wang G, Li X. Endoscopic Management of Adult Primary Obstructive Megaureter: Techniques and Long-term Outcomes. EUR UROL SUPPL 2024; 68:18-24. [PMID: 39257619 PMCID: PMC11381473 DOI: 10.1016/j.euros.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/12/2024] Open
Abstract
Background and objective Few studies on endoscopic management of primary obstructive megaureter (POM) in adult patients have been reported. Our objective was to describe our technique and long-term outcomes for endoscopic management of adult POM. Methods We included 76 adult POM patients undergoing endoscopic management between September 2015 and January 2024. Under endoscopic control, the stricture was dilated to 24-30 Fr while maintaining a balloon pressure of 25-35 atm for 3 min. An additional incision of the stenotic ring using either an electrode or holmium laser was performed in 39 patients. Data for patient characteristics, intraoperative variables, surgical complications, and follow-up results were analyzed. A descriptive statistical analysis was performed. Surgical success was defined as no tubes or stents in the body, stable or improved symptoms and renal function, and the absence of reflux or obstruction during the follow-up period. Key findings and limitations All procedures were completed without conversion to open or laparoscopic surgery. The median operative time was 45 min (range 16-165) with median estimated blood loss of 2 ml (range 0-150). The median postoperative hospital stay was 3 d (range 1-15). No intraoperative complication occurred. At median postoperative follow-up of 42 mo (range 3-100) the overall success rate was 92.1%. Restenosis of the vesicoureteral junction (Clavien-Dindo grade III) occurred in five patients (6.6%), and high-grade vesicoureteral reflux occurred in one patient (1.3%), all of whom required secondary reconstruction surgery. Conclusions and clinical implications The results indicate that our endoscopic management for adult POM is safe and effective, with favorable long-term outcomes. This approach could potentially serve as a first-line treatment option for adult POM. Patient summary Primary obstructive megaureter (POM) occurs when the flow of urine is blocked because of a narrow segment in the tube between the kidney and bladder (ureter), which causes widening of the ureter further up. For our minimally invasive technique, a telescope is inserted through the urethra and bladder to reach the ureter for surgical treatment. Our results show that this is a safe procedure for POM in adults.
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Affiliation(s)
- Zhenyu Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Kunlin Yang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Yicong Du
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Xinfei Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Zhihua Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Bing Wang
- Department of Urology, Miyun Hospital, Peking University First Hospital, Beijing, China
| | - Chen Huang
- Department of Urology, Beijing Jiangong Hospital, Beijing, China
| | - Silu Chen
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Yiming Zhang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Hongjian Zhu
- Department of Urology, Beijing Jiangong Hospital, Beijing, China
| | - Peng Zhang
- Department of Urology, Emergency General Hospital, Beijing, China
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Gang Wang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
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Boswell TC. Advancements in Surgical Management of Megaureters. Curr Urol Rep 2024; 25:215-223. [PMID: 38954357 PMCID: PMC11306539 DOI: 10.1007/s11934-024-01214-8] [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] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To review and describe the recent evolution of surgery for the various types of pediatric megaureter. RECENT FINDINGS Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.
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Affiliation(s)
- Timothy C Boswell
- Department of Urology, Children's of Alabama and University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 318, Birmingham, AL, 35233, USA.
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Pérez-Bertólez S, Martín-Solé O, Casal-Beloy I, Carbonell M, Salcedo P, Capdevila B, García-Aparicio L. Risk and protective factors for secondary procedures after endoscopic dilatation of primary obstructive megaureters. World J Urol 2024; 42:463. [PMID: 39088058 DOI: 10.1007/s00345-024-05181-0] [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: 05/03/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
PURPOSE High-pressure balloon dilatation (HPBD) of the ureterovesical junction with double-J stenting is a minimally invasive alternative to ureteral reimplantation or cutaneous ureterostomy for first-line surgical treatment of primary obstructive megaureter (POM). The aim of our study was to identify the risk factors associated with the need for secondary procedures due to HPBD failure. METHODS Prospective data were collected from patients who underwent HPBD for POM between 2007 and 2021 at a single institution. The collected data included patient demographics, diagnostic modalities, surgical details, results, and follow-up. Multivariate logistic regression analysis was performed. RESULTS Fifty-five ureters underwent HPBD for POM in 50 children, with a median age of 6.4 months (IQR: 4.5-13.8). Nineteen patients (37.25%) underwent secondary ureteric reimplantation, with a median of 9.8 months after primary HBPD (95% CI 6.2-9.9). The median follow-up was 29.4 months (IQR: 17.4-71). Independent risk factors for redo-surgery in a multivariate logistic regression model were: progressive ureterohydronephrosis (OR = 7.8; 95% CI 0.77-78.6) and early removal of the double-J stent. A risk reduction of 7% (95% CI 2.2%-11.4%) was observed per extra-day of catheter maintenance. The optimal cut-off point is 55 days, ROC curve area: 0.77 (95% CI 0.62-0.92). Gender, distal ureteral diameter, pelvis diameter, dilatation balloon diameter and preoperative differential renal function did not affect the need for reimplantation. CONCLUSIONS The use of a double-J stent for at least 55 days seems to avoid the need for a secondary procedure. Therefore, we recommend removing the double-J catheter at least 2 months after the HBPD.
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Affiliation(s)
- Sonia Pérez-Bertólez
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain.
| | - Oriol Martín-Solé
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Isabel Casal-Beloy
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Mar Carbonell
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Paula Salcedo
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Blanca Capdevila
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Luis García-Aparicio
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
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Rivetti G, Marzuillo P, Guarino S, Di Sessa A, La Manna A, Caldamone AA, Papparella A, Noviello C. Primary non-refluxing megaureter: Natural history, follow-up and treatment. Eur J Pediatr 2024; 183:2029-2036. [PMID: 38441661 PMCID: PMC11035438 DOI: 10.1007/s00431-024-05494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/17/2024] [Accepted: 02/23/2024] [Indexed: 04/23/2024]
Abstract
Primary non-refluxing megaureter (PMU) is a congenital dilation of the ureter which is not related to vesicoureteral reflux, duplicated collecting systems, ureterocele, ectopic ureter, or posterior urethral valves and accounts for 5 to 10% of all prenatal hydronephrosis (HN) cases. The etiology is a dysfunction or stenosis of the distal ureter. Most often PMU remains asymptomatic with spontaneous resolution allowing for non-operative management. Nevertheless, in selective cases such as the development of febrile urinary tract infections, worsening of the ureteral dilatation, or reduction in relative renal function, surgery should be considered. CONCLUSION Ureteral replantation with excision of the dysfunctional ureteral segment and often ureteral tapering is the gold-standard procedure for PMU, although endoscopic treatment has been shown to have a fair success rate in many studies. In this review, we discuss the natural history, follow-up, and treatment of PMU. WHAT IS KNOWN • PMU is the result of an atonic or stenotic segment of the distal ureter, resulting in congenital dilation of the ureter, and is frequently diagnosed on routine antenatal ultrasound. WHAT IS NEW • Most often, PMU remains asymptomatic and clinically stable, allowing for non-operative management. • Nevertheless, since symptoms can appear even after years of observation, long-term ultrasound follow-up is recommended, even up to young adulthood, if hydroureteronephrosis persists. • Ureteral replantation is the gold standard in case surgery is needed. In selected cases, however, HPBD could be a reasonable alternative.
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Affiliation(s)
- Giulio Rivetti
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy.
| | - Stefano Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Anna Di Sessa
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Angela La Manna
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Anthony A Caldamone
- Division of Urology, Warren Alpert School of Medicine at Brown University/Hasbro Children's Hospital, Providence, RI, USA
| | - Alfonso Papparella
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Carmine Noviello
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, 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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Ripatti L, Viljamaa HR, Suihko A, Pakkasjärvi N. 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] [MESH Headings] [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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Affiliation(s)
- Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland.
| | - Hanna-Reeta Viljamaa
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
| | - Anna Suihko
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
| | - Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
- Department of Pediatric Surgery, Uppsala Akademiska Sjukhuset, Uppsala, Sweden
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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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Lin S, Xu D, He S, Li L, Xu H, Tang K. Ureteral reimplantation for pediatric vesicoureteral reflux and primary obstructive megaureter: Transvesicoscopic cohen vs. Politano-Leadbetter approaches. J Pediatr Urol 2022; 18:516.e1-516.e9. [PMID: 35659823 DOI: 10.1016/j.jpurol.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transvesicoscopic approaches for ureteral reimplantation (UR) are effective surgical techniques with which to resolve vesicoureteral reflux (VUR) or primary obstructive megaureter (POM) in pediatric patients. However, the effectiveness of different UR surgical methods for these two diseases is still unclear. PURPOSE To compare the effects of Cohen's cross-trigonal and Politano-Leadbetter techniques in children in need of UR. METHODS A retrospective chart review was performed for consecutive patients who underwent UR at our institution between May 2018 and November 2019, including those treated for vesicoureteral reflux (VUR) or primary obstructive megaureter (POM). Patients who underwent Cohen's technique included in Group C, and those who underwent the Politano-Leadbetter technique were included in Group P. Patient characteristics, perioperative parameters, and short-term postoperative outcomes were compared. RESULTS Forty-six patients who underwent unilateral UR were included in the analysis. At presentation, those in Group P (N = 22, 12 diagnosed with VUR and 10 with POM) did not differ from those in Group C (N = 24, 12 diagnosed with VUR and 12 with POM) with respect to age, sex, disease type or severity. For VUR patients, reflux was clinically resolved for all patients in both groups; however, only a 75% resolution rate was observed in Group C, with 3 patients experiencing persistent low-grade, clinically insignificant reflux, while a 100% resolution rate was found in Group P (P > 0.05). Among POM patients, the obstruction was resolved for all those in Group P and for 90% of those in Group C; this difference was also not statistically significant (P > 0.05). At the 1-year follow-up, the ureteral diameter (P < 0.05) and anterior-posterior renal pelvic diameter (APRPD) (P < 0.05) of Group P were significantly reduced, and differential renal function (DRF) (P < 0.05) was slightly improved compared with that in Group C in both VUR and POM patients. CONCLUSIONS Politano-Leadbetter and Cohen are both reliable techniques for UR in children with VUR or POM, and the short-term outcomes of these methods in solving reflux and obstruction are comparable. Besides traditional Cohen's technique, Politano-Leadbetter's technique maybe a potential choice for ureteral reimplantation in children.
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Affiliation(s)
- Shan Lin
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
| | - Di Xu
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
| | - Shaohua He
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
| | - Lizhi Li
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
| | - Huihuang Xu
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
| | - Kunbin Tang
- Shengli Clinical Medical College of Fujian Medical University, Department of Pediatric Surgery, Fujian Provincial Hospital, Fuzhou, Fujian 350001, China.
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10
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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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Zukunftsprägende Entwicklungen in der Kinderurologie. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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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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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