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Contini G, Mele E, Barneschi AC, Esposito C, Castagnetti M. Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do? Pediatr Surg Int 2024; 40:103. [PMID: 38598017 PMCID: PMC11006722 DOI: 10.1007/s00383-024-05665-5] [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] [Accepted: 02/21/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED). MATERIALS AND METHODS This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups. RESULTS Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections. CONCLUSIONS SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.
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Affiliation(s)
- Giorgia Contini
- Division of Pediatric Urology, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy
| | - Ermelinda Mele
- Division of Pediatric Urology, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy
| | - Andrea Celeste Barneschi
- Division of Pediatric Urology, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy
| | - Ciro Esposito
- Division of Pediatric Surgery, Federico II University of Naples, Naples, Italy
| | - Marco Castagnetti
- Division of Pediatric Urology, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy.
- Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy.
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Wahyudi I, Risky Raharja PA, Situmorang GR, Rodjani A. Associations of ureteroceles location and system anatomy with outcomes of endoscopic treatment: A systematic review and meta-analysis. J Pediatr Urol 2023; 19:626-636. [PMID: 37244837 DOI: 10.1016/j.jpurol.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/25/2023] [Accepted: 05/05/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Ureteroceles are a congenital abnormality of the ureter that can cause significant complications. Endoscopic treatment is a commonly used treatment approach. The aim of this review is to assess the results of endoscopic treatment for ureteroceles with consideration to their location and system anatomy. METHODS A meta-analysis was conducted by searching electronic databases for studies comparing outcomes of endoscopic treatment for ureteroceles. Newcastle-Ottawa Scale (NOS) was employed to evaluate the potential for bias. The primary outcome was the rate of secondary procedures required following endoscopic treatment. Secondary outcomes were inadequate drainage and post-operative vesicoureteral reflux (VUR) rates. A subgroup analysis was performed to investigate possible causes of heterogeneity in the primary outcome. The statistical analysis was conducted using Review Manager 5.4. RESULTS There were 28 retrospective observational studies, published between 1993 and 2022, including 1044 patients with primary outcomes in this meta-analysis. The quantitative synthesis showed that ectopic and duplex system ureteroceles were significantly associated with higher rate of secondary operation compared to intravesical and single system ureteroceles, respectively (OR: 5.42, 95% CI: 3.93-7.47; and OR: 5.10, 95% CI: 3.31-7.87). The associations were still significant in subgroup analysis based on follow up duration, average age at surgery, and duplex system only. For secondary outcomes, incidence of inadequate drainage were significantly higher in ectopic (OR: 2,01, 95% CI: 1.18-3.43), but not in duplex system ureteroceles (OR: 1.94, 95% CI: 0,97-3.86). Post-operative VUR rates were higher in both ectopic (OR: 1.79, 95% CI: 1.29-2.47) and duplex system ureteroceles group (OR: 1.88, 95% CI: 1.15-3.08). CONCLUSION Ectopic ureteroceles and duplex system ureteroceles were associated with worse outcomes following endoscopic treatment compared to intravesical and single system ureteroceles, respectively. It is recommended to carefully select patients, conduct pre-operative evaluations, and closely monitor patients with ectopic and duplex system ureteroceles.
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Affiliation(s)
- Irfan Wahyudi
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jalan Diponegoro No. 71, Jakarta 10430, Indonesia.
| | - Putu Angga Risky Raharja
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jalan Diponegoro No. 71, Jakarta 10430, Indonesia
| | - Gerhard Reinaldi Situmorang
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jalan Diponegoro No. 71, Jakarta 10430, Indonesia
| | - Arry Rodjani
- Department of Urology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jalan Diponegoro No. 71, Jakarta 10430, Indonesia
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Smith BR, Smith CJ, Sharma K, Sheth KR. Factors of transurethral incision effectiveness for ureteroceles in pediatric patients: A 28-year, single-institution retrospective review. J Pediatr Urol 2023; 19:536.e1-536.e8. [PMID: 37002026 DOI: 10.1016/j.jpurol.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND As a congenital anomaly, ureteroceles occur in 1 in 4000 children, and are usually diagnosed prenatally. However, there remains a lack of definite consensus on the optimal management of congenital ureteroceles. OBJECTIVE We evaluated factors associated with success of primary transurethral incision (TUI) in ureterocele pediatric patients. METHODS Demographic and clinical information for 120 pediatric patients who were diagnosed with congenital ureterocele between 1993 and 2021 at our institution were obtained through retrospective chart review. Data were analyzed using Fisher's exact tests, t-tests, and logistic regression with a significance threshold of p < 0.05. The primary outcome of ureterocele management was TUI effectiveness, defined by no need for further surgical intervention. RESULTS Of the 120 patients (39 boys, 81 girls) with ureteroceles, 75 patients (22 boys, 53 girls) met our inclusion criteria of undergoing initial TUI ureterocele. Initial TUI was effective in 51/75 patients (68.0%). We analyzed possible correlative factors for TUI efficacy. Simplex system was a significant predictor of primary TUI efficacy (85% effective in simplex systems, 62% in duplex systems). Prior urinary tract infection, prenatal diagnosis, and electrocautery technique were all associated with an increased risk of needing additional surgeries after primary TUI. DISCUSSION The most significant predictors of effective primary TUI were simplex system and the absence of preoperative vesicoureteral reflux. Prenatal diagnosis, preoperative febrile urinary tract infection, higher preoperative hydronephrosis grade, and the use of electrocautery were all associated with decreased primary TUI efficacy. Study limitations include that it was a retrospective chart review, and cohort size was limited by incomplete urology follow-up and operative records. CONCLUSIONS Initial TUI was an effective procedure for the majority of our pediatric ureterocele patients, a higher success rate compared to other cohorts. Patients with a simplex system were more likely to have an effective first TUI than patients with duplex systems, as were patients without preoperative reflux. Although not statistically significant, our data suggest prior UTI, prenatal diagnosis, higher preoperative hydronephrosis grade, and the use of electrocautery may be associated with having additional surgeries.
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Affiliation(s)
- Brian R Smith
- Department of Urology, Stanford University School of Medicine, 750 Welch Rd, Suite 218, Palo Alto, CA 94304, USA.
| | - Courtney J Smith
- Department of Genetics, Stanford University School of Medicine, 318 Campus Drive, Stanford, CA 94305, USA.
| | - Kritika Sharma
- Department of Urology, Stanford University School of Medicine, 750 Welch Rd, Suite 218, Palo Alto, CA 94304, USA.
| | - Kunj R Sheth
- Department of Urology, Stanford University School of Medicine, 750 Welch Rd, Suite 218, Palo Alto, CA 94304, USA.
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Yin X, Yang Y. Risk factors for postoperative adverse outcomes and secondary surgery in pediatric patients with unilateral ectopic ureterocele associated with the duplex system. J Pediatr Urol 2023; 19:88.e1-88.e8. [PMID: 36336622 DOI: 10.1016/j.jpurol.2022.10.022] [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: 04/26/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Ectopic ureterocele management in children remains a controversial subject without a clear consensus. The purpose of this study was to explore the risk factors for adverse outcomes and secondary surgery in pediatric patients with unilateral ectopic duplex system ureterocele, a complex urinary system deformity with controversial treatment. MATERIALS AND METHODS We retrospectively reviewed 75 patients with unilateral ectopic duplex system ureterocele who underwent surgery at the Shengjing Hospital of China Medical University between January 1, 2008, and September 31, 2020. Demographic characteristics, preoperative data, surgical procedures, postoperative adverse outcomes, and secondary surgery were recorded. Adverse outcomes were defined as new-onset VUR and BOO after surgery. The risks of adverse outcomes and secondary surgery were evaluated using multivariate binary logistic regression and expressed as adjusted odds ratios with 95% confidence intervals. RESULTS Adverse outcomes occurred in 25 (33.3%) patients, including 24 (32.0%) with new-onset vesicoureteral reflux and 1 (1.3%) with bladder outlet obstruction. Seven (9.3%) patients required secondary surgery. The independent risk factors for adverse outcomes were transurethral endoscopic incision and transurethral endoscopic puncture (transurethral endoscopic incision vs. upper pole partial nephrectomy: OR = 11.049, P = 0.004; transurethral endoscopic puncture vs. upper pole partial nephrectomy: OR = 33.222, P = 0.002). DISCUSSION The definitive treatment for duplex system ureterocele remains controversial. We found that transurethral endoscopic incision or puncture was an independent risk factor for adverse outcomes. The main limitation of this study would be its retrospective nature and relatively short follow-up period. Furthermore, 30 children were younger than 5 years at last follow up, and thus, we could not efficiently evaluate their voiding function. CONCLUSIONS Transurethral endoscopic incision or puncture is effective for decompressing the obstruction of the upper urinary tract in acute urosepsis in ectopic duplex system ureterocele. Although more than half of patients with unilateral ectopic duplex system ureterocele suffered from new-onset vesicoureteral reflux after transurethral endoscopic incision or puncture, few of them required secondary surgery.
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Affiliation(s)
- Xiaoming Yin
- Department of Pediatric Urology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang City, Liaoning province 110004, China
| | - Yi Yang
- Department of Pediatric Urology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang City, Liaoning province 110004, China.
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Endoscopic treatment of ureterocele in children: Results of a single referral tertiary center over a 10 year-period. J Pediatr Urol 2022; 18:182.e1-182.e6. [PMID: 35067454 DOI: 10.1016/j.jpurol.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The management of UCs remain controversial, especially for UCs with duplex collecting systems that still represent a great challenge in paediatric urology. Several approaches have been used and a shared management is not yet validated. STUDY AIM Aim of our study is to evaluate the results of the endoscopic treatment of UC comparing ortothopic single-system UC and ectopic duplex-system UC over a 10-year period in a single referral tertiary center. Success was defined as resolution of dilation, lack of urinary infections and preservation of renal function. STUDY DESIGN We retrospectively reviewed medical records of children with a diagnosis of UC who underwent endoscopic puncture at our division from January 2009 to January 2019. Patients were divided in two groups: Group A composed of patients with ectopic UC associated with renal duplex system and Group B with orthotopic UC in single collecting system. RESULTS We identified 48 paediatric patients treated with transurethral primary endoscopic incision. Groups result homogeneous for clinical and pathological characteristics. The only statistical significative difference between the two samples was the age at diagnosis (p value with Yates correction = 0.01). DISCUSSION We considered as a therapeutic success infections control and the elimination of obstruction with preservation of global kidney function. Based on that, our success rate after single (77%) or double (92%) endoscopic treatment is higher than data reported in literature. Differently from previous studies, vescico-ureteral reflux without UTIs was not considered as a failure of the procedure. The present study has some limitations: it is a retrospective and monocentric serie and it lacked a longer follow-up; on the other hand, it has been conducted on a quite large sample size and it is one of the few studies that compares the endoscopic treatment between orthotopic and ectopic UC. CONCLUSION Our data report primary endoscopic puncture of ureterocele as a simple, effective, and safe procedure also in long-term follow up. This technique avoids the need for additional surgery in the majority of the patients, also in the case of an ectopic UC associated to a duplex system.
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Jain V, Agarwala S, Dhua A, Mitra A, Mittal D, Murali D, Kandasamy D, Kumar R, Bhatnagar V. Management and outcomes of ureteroceles in children: An experience of 25 years. Indian J Urol 2021; 37:163-168. [PMID: 34103800 PMCID: PMC8173935 DOI: 10.4103/iju.iju_522_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/01/2020] [Accepted: 02/05/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Ureterocele is a rare urogenital malformation. The treatment is variable and complicated as it depends on several factors. The aim of this study was to evaluate the management and outcomes of children with ureterocele and to compare single system and duplex system ureteroceles. Materials and Methods: A retrospective study was conducted and all patients with ureterocele operated from January 1992 to December 2018 were included. The records of those included were assessed, and a detailed case record sheet was filled. The outcome parameters assessed were the persistence of symptoms and additional surgical procedure performed. Results: Forty-seven patients (28 boys and 19 girls) with a median age of presentation of 21 months were included. Four patients had bilateral ureterocele. Overall, 51 renal units with ureterocele were studied. Twenty renal units of the 31 renal units with duplex system underwent cystoscopic decompression, and of these, 8 (40%) needed a second procedure. Fourteen renal units of the remaining 20 renal units with single system underwent cystoscopy and decompression, and of these, 1 (7%) required another procedure (P = 0.024). Sixteen renal units had ectopic ureterocele, of which 9 (56%) underwent heminephrectomy/nephrectomy. Intravesical ureterocele was present in 35 renal units, of which only 2 (5.7%) underwent nephrectomy or heminephrectomy (P < 0.001). Conclusion: Duplex system ureteroceles are more likely to require a second procedure following an endoscopic puncture. Units with ectopic ureterocele were more likely to need nephrectomy.
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Affiliation(s)
- Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Aparajita Mitra
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Mittal
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Divya Murali
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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A novel approach for an old debate in management of ureterocele: long-term outcomes of double-puncture technique. J Pediatr Urol 2019; 15:389.e1-389.e5. [PMID: 31175023 DOI: 10.1016/j.jpurol.2019.04.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 11/23/2022]
Abstract
INTRODUCTION To date, the optimal surgical technique for ureterocele complex remains unclear and a diverse range of management options have been suggested. Some endoscopic approaches share major drawbacks such as de novo vesicoureteral reflux (VUR) into ureterocele moiety that can mandate revision surgery. OBJECTIVE In this study, long-term outcomes of double-puncture technique are evaluated. MATERIAL AND METHODS Records of patients treated by double-puncture technique between 1999 and 2014 were reviewed. Patients with a history of previous ureterocele surgery, follow-up period of less than two years, or an orthotopic ureterocele were excluded. In this technique, a double-J stent is inserted into two punctured sites at the poles of an ectopic ureterocele. Subsequently, anterior and posterior collapsed walls of a ureterocele were fulgurated at multiple points to create surface welding of the urine channel. Follow-up data regarding success of ureterocele decompression, de novo VUR, febrile urinary tract infection (UTI), and the need for further intervention were recorded. RESULTS Forty-eight patients (51 ureteroceles) were assessed in this study. Bilateral ureterocele double puncture was performed for three patients (6.3%). Mean (range) age at the time of surgery was 2.9 (2 months-13 years) years. Mean follow-up was 6.1 (2-15.2) years. Successful decompression was achieved in all except two ureteroceles (success rate = 96.1%) (Summary Figure). New-onset VUR to punctured moiety was diagnosed in another two patients. No postoperative febrile UTI was encountered. CONCLUSIONS Double-puncture technique is a successful endoscopic intervention for immediate and durable decompression of ectopic ureteroceles without incurring major complications.
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Song SH, Lee DH, Kim H, Lee J, Lee S, Ahn D, Park S, Kim KS. Impact of de novo vesicoureteral reflux on transurethral surgery outcomes in pediatric patients with ureteroceles. Investig Clin Urol 2019; 60:295-302. [PMID: 31294139 PMCID: PMC6607067 DOI: 10.4111/icu.2019.60.4.295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 04/28/2019] [Indexed: 11/21/2022] Open
Abstract
Purpose We aimed to determine the impact of de novo vesicoureteral reflux (VUR) on postoperative urinary tract infection (UTI) and renal function in pediatric patients with ureteroceles. Materials and Methods We retrospectively reviewed the medical records of 34 patients (36 renal units) with ureteroceles that were treated endoscopically. Perioperative radiologic and clinical data regarding de novo VUR, UTI, and renal function were analyzed. Logistic regression analysis was used to identify factors that predicted unfavorable surgical outcomes, such as primary surgical failure, postoperative UTI, and deterioration of renal function. Results Of the 36 renal units, 22 had a duplex system (61.1%). Preoperative VUR was noted in 9 units (25.0%), including 3 units without renal duplication. Endoscopic surgery successfully decompressed the ureterocele and hydronephrosis in 28 units (77.8%). De novo VUR developed in 18 renal units (50.0%) postoperatively. The absence or presence of de novo VUR was not related to unfavorable surgical outcomes in univariate or multivariate analyses. Even after selection for the 28 renal units without preoperative VUR, the occurrence of de novo VUR had no predictive value for unfavorable surgical outcomes. Moreover, among the 14 renal units without renal duplication, de novo VUR had no predictive value for any of these adverse outcomes. Conclusions After endoscopic ureterocele puncture, de novo VUR is not significantly associated with postoperative UTI or deterioration in renal function in the long term. It may not, therefore, be necessary to reconstruct lower urinary tract routinely to correct de novo VUR after endoscopic puncture of the ureterocele.
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Affiliation(s)
- Sang Hoon Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwiwoo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jongpil Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sangmin Lee
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Donghyun Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungchan Park
- Department of Urology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kun Suk Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter? J Pediatr Urol 2019; 15:50.e1-50.e6. [PMID: 30243559 DOI: 10.1016/j.jpurol.2018.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/10/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes. MATERIALS AND METHODS All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes. RESULTS The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery. CONCLUSION Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.
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Does endoscopic puncture of ureterocele provide not only an initial solution, but also a definitive treatment in all children? Over the 26 years of experience. Pediatr Surg Int 2018; 34:561-565. [PMID: 29594460 DOI: 10.1007/s00383-018-4258-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE We have retrospectively evaluated all patients who underwent endoscopic puncture (EP) of ureterocele over the last 26 years with special reference to the need in the second intervention and disease-free status. METHODS 78 (69%) of the 112 patients following EP and completed follow-up were included. 51 (65%) were diagnosed prenatally and 27 (35%) postnatally. 46 patients (60%) had intravesical, while 32 (40%) had ectopic ureterocele. Median age at time of puncture was 4 months. Median time of the follow-up was 12 years (range 1-26 years), while 23 (30%) followed over 10 years and 15 (19%) completed adolescent period. RESULTS Four children with ectopic ureterocele required secondary puncture. Ectopic ureterocele children had significantly more postoperative UTIs (13 (40%) ectopic vs 4 (19%) intravesical p = 0.047). 19 RRUs (44%) showed spontaneous resolution of VUR. 14 (18%) children required additional surgery: 7, endoscopic correction of VUR; 3, ureteral reimplantation and 4, partial nephrectomy. The need for additional surgery following puncture was higher in the group of children with ectopic ureterocele; however, this difference did not reach a statistical significance (p = 0.716). CONCLUSIONS Our data show that EP of ureterocele is a durable and long-term effective procedure in vast majority of the children.
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Moriya K, Nakamura M, Nishimura Y, Kanno Y, Kitta T, Kon M, Shinohara N. Prevalence of and risk factors for symptomatic urinary tract infection after endoscopic incision for the treatment of ureterocele in children. BJU Int 2017; 120:409-415. [DOI: 10.1111/bju.13884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kimihiko Moriya
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Michiko Nakamura
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Yoko Nishimura
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Yukiko Kanno
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Takeya Kitta
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Masafumi Kon
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Nobuo Shinohara
- Department of Renal and Genitourinary Surgery; Hokkaido University Graduate School of Medicine; Sapporo Japan
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Bilgutay AN, Roth DR, Gonzales ET, Janzen N, Zhang W, Koh CJ, Gargollo P, Seth A. Posterior urethral valves: Risk factors for progression to renal failure. J Pediatr Urol 2016; 12:179.e1-7. [PMID: 26705688 PMCID: PMC4882264 DOI: 10.1016/j.jpurol.2015.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 10/22/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Posterior urethral valves (PUVs) are the most common etiology for congenital urethral obstruction and congenital bilateral renal obstruction. PUVs produce a spectrum of urologic and renal sequelae. Our aims were to assess outcomes of PUV patients, to determine whether vesicoureteral reflux (VUR) is a risk factor for progression to renal failure, and to identify other risk factors for poor outcomes. MATERIALS AND METHODS We conducted a retrospective analysis of PUV patients from 2006 to 2014. Data collected included demographics, initial renal ultrasound (RUS) findings, creatinine at presentation and nadir, pre- and postoperative VUR status, presence or absence of recurrent urinary tract infections (UTIs), and surgical intervention(s). Univariate and multivariate analyses were used to determine risk factors for renal failure. RESULTS Of 104 patients, 42.3% (44/104) were diagnosed prenatally, 31.8% (14/44) of whom underwent prenatal intervention. Postnatally, 90.4% (94/104) initially underwent transurethral resection of PUVs (TUR-PUVs). Vesicostomy was the next most common index surgery (4.8%). Forty-two percent (44/104) required >1 surgery. The predominant second surgery was repeat TUR-PUV in 16 patients. At last follow-up (mean 28.8 months after initial surgery), 20.2% had chronic kidney disease (CKD) of at least stage IIIA, and 8.6% had progressed to end-stage renal disease (ESRD). Antenatal diagnosis, prematurity, abnormal renal cortex, and loss of corticomedullary differentiation (CMD) on initial RUS were associated with CKD and ESRD on univariate analysis, as were elevated creatinine on presentation and at nadir. Presence of pre- or postoperative VUR and recurrent UTIs were associated with the need for multiple surgeries, but not with poor renal outcomes. On multivariate analysis, nadir creatinine was the only independent predictor of final renal function. CONCLUSIONS Our finding that creatinine is the only independent risk factor for poor renal outcomes in PUV patients is consistent with the literature. The effect of VUR has been controversial, and our finding that VUR is associated with need for multiple surgeries but not with CKD or ESRD is novel. Limitations include biases inherent to retrospective studies and relatively small sample size. The majority of patients with PUVs (56.7%) required one surgery and maintained renal function with CKD II or better (79.8%) up to 2 years after initial surgery. While multiple factors were associated with poor renal outcomes, nadir creatinine was the only independent predictor. VUR and recurrent UTIs were not associated with poor renal outcomes. Longer follow-up is necessary to identify risk factors for delayed progression of renal disease.
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Affiliation(s)
- Aylin N Bilgutay
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - David R Roth
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Edmond T Gonzales
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Nicolette Janzen
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Wei Zhang
- Texas Children's Hospital, Houston, TX, USA
| | - Chester J Koh
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Patricio Gargollo
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Abhishek Seth
- Texas Children's Hospital, Houston, TX, USA; Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA.
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Obara K, Anraku T, Ikeda M, Komatsu S, Mizusawa T, Maruyama R, Tomita Y. Case of Large Cecoureterocele with Contralateral Renal Rupture in Neonate. Urol Int 2016; 97:238-40. [PMID: 27045294 DOI: 10.1159/000445525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/17/2016] [Indexed: 11/19/2022]
Abstract
A cecoureterocele is a rare form of ectopic ureterocele that the orifice of the affected ureter is within the bladder, but the cavity of the ureterocele extends beyond the bladder neck into the urethra. We present a case of a newborn boy with a large cecoureterocele with contralateral renal rupture. He required an emergency transurethral incision of the ureterocele for the treatment of acute renal failure and respiratory disorder.
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Affiliation(s)
- Kenji Obara
- Division of Urology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Evaluation of the Initial Treatment of Ureteroceles. Urology 2016; 89:113-7. [DOI: 10.1016/j.urology.2015.11.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/15/2015] [Accepted: 11/18/2015] [Indexed: 11/22/2022]
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Liu C, Chen W, Xie C, Guan W, Zhao Y, Ouyang Y, Xu Y, Wu Y, Wang X, Wang Y, Zhang X. Efficacy and Safety of Transurethral Photoselective Greenlight(™) Laser Vaporization for the Treatment of Orthotopic Ureteroceles in Adults. Photomed Laser Surg 2015; 33:326-9. [PMID: 26067941 DOI: 10.1089/pho.2015.3889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to retrospectively evaluate the safety and efficacy of transurethral photoselective Greenlight(™) laser vaporization in adult patients with orthotopic ureterocele. MATERIALS AND METHODS Thirty adult patients diagnosed with orthotopic urecterocele were recruited at our center. Transurethral photoselective Greenlight laser vaporization was used as the exclusive technique for endoscopic management during the study period. Information, including age, gender, mode of presentation, ureterocele size, vesicoureteral reflux, hydronephrosis status, and incidence of reoperation, were collected for evaluation. RESULTS Our series included 12 men and 18 women. The mean patient age at presentation was 30.5 years (range, 18-62 years). The mean size of ureterocele was 18 mm (range, 10-41 mm). All patients successfully underwent transurethral photoselective Greenlight laser to vaporize the ureterocele. The operation ranged from 13 min to 38 min (mean 19.6 min). The average blood loss was <10 mL. No patient had intraoperative complications. The average postoperative hospital stay was 18.3 h. All patients were voided after postoperative catheter removal. None of the patients demonstrated any residual ureterocele and/or hydronephrosis when evaluated with ultrasonography after 3 months. Only one patient with a duplex collecting system presented asymptomatic low-grade reflux at 3 months, which was spontaneously resolved after 6 months of follow-up. All patients were free of any symptoms. No reoperative procedures were required at a mean follow-up of 14.2 months (range, 8-16). CONCLUSIONS Transurethral photoselective Greenlight laser vaporization is safe, effective, and efficient for the management of orthotopic urecteroceles in adults. Therefore, this technique should be considered as the initial treatment in most patients.
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Affiliation(s)
- Cuilong Liu
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Weihao Chen
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Changliang Xie
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Weimin Guan
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Yubo Zhao
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Yun Ouyang
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Yansheng Xu
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Yiguang Wu
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Xiyou Wang
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Yi Wang
- Department of Urology, General Hospital of the Navy , Beijing, China
| | - Xinyu Zhang
- Department of Urology, General Hospital of the Navy , Beijing, China
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Sander JC, Bilgutay AN, Stanasel I, Koh CJ, Janzen N, Gonzales ET, Roth DR, Seth A. Outcomes of endoscopic incision for the treatment of ureterocele in children at a single institution. J Urol 2014; 193:662-6. [PMID: 25167992 DOI: 10.1016/j.juro.2014.08.095] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE We assessed outcomes in children with ureterocele after transurethral incision at our institution between 2001 and 2014, focusing on end points of vesicoureteral reflux, improvement of hydronephrosis and need for second surgery. MATERIALS AND METHODS We performed chart reviews of 83 patients, collecting information including age at transurethral incision, gender, renal anatomy, ureterocele location, indication for transurethral incision, and preincision and postincision vesicoureteral reflux and hydronephrosis status. Patients were divided into those with single system and duplex system ureteroceles, and intravesical and extravesical location for analysis. Statistical evaluations were performed with the Wilcoxon rank test and Fisher exact test. RESULTS Transurethral incision was performed at a mean age of 34.2 months in patients with single system ureterocele and 8.9 months in those with duplex system ureterocele (p <0.0001). Cure rates (improvement of hydronephrosis and absence of vesicoureteral reflux) were 55.6% in patients with single system ureterocele and 14.9% in those with duplex system ureterocele (p = 0.0031). Rates of de novo reflux into the ureterocele moiety were 27.8% for patients with single system ureterocele and 56.2% for those with duplex system ureterocele (p = 0.0773). Patients with single system ureterocele required significantly fewer second surgeries (3.8%) than those with duplex system ureterocele (73.7%, p <0.0001). CONCLUSIONS Patients with single system ureterocele may benefit from endoscopic incision. Transurethral incision was definitive in all such patients except 1 in our study. Although most patients with duplex system ureterocele will need a second operation, transurethral incision remains of value in this population in instances of sepsis or bladder outlet obstruction, or to facilitate planned reconstruction when the child is older.
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Affiliation(s)
- James C Sander
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Aylin N Bilgutay
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Irina Stanasel
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Chester J Koh
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Nicolette Janzen
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Edmond T Gonzales
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - David R Roth
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas
| | - Abhishek Seth
- Scott Department of Urology, Baylor College of Medicine (ANB) and Texas Children's Hospital, Houston, Texas.
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Ellerkamp V, Szavay P, Luithle T, Schäfer JF, Amon O, Fuchs J. Single-stage surgical approach in complicated paediatric ureteral duplication: surgical and functional outcome. Pediatr Surg Int 2014; 30:99-105. [PMID: 24072201 DOI: 10.1007/s00383-013-3411-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE Surgical approach to children with complicated ureteral duplication is discussed controversially. Our aim was to determine the outcome of children with complicated renal duplication undergoing a single-stage surgical approach with laparoscopic partial nephrectomy and open bladder reconstruction. METHODS Data of patients from 2004 to 2008 were investigated retrospectively. Outcome was analyzed in terms of postoperative course, renal function, urinary tract infection and functional voiding. RESULTS Thirteen patients were treated with laparoscopic partial nephrectomy and reconstruction of the lower urinary tract in a single-stage approach. Median age at operation was 15 months (2-63 m). One girl had a renal triplication. 7/13 patients presented with an ectopic ureterocele, two with an ectopic ureter, severe vesicoureteral reflux occurred in 6 patients. All patients had non-functioning renal moieties. Mean operative time was 239 min (129-309; SD 50). One re-operation was necessary 4 years after primary surgery due to a pole remnant. All patients had uneventful recoveries without evidence of recurrent UTI. Postoperative 99mTc-MAG3 scans showed no significant reduction of partial renal function (p = 0.4), and no signs of obstruction (p = 0.188). During a median follow-up of 60 months (49-86), dysfunctional voiding occurred in one patient. CONCLUSIONS In children with complicated ureteral duplication a definitive single-stage procedure is feasible and shows excellent functional results.
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Affiliation(s)
- Verena Ellerkamp
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Hoppe-Seyler-Str. 2, 72076, Tuebingen, Germany,
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Duplex system ureterocele in infants: should we reconsider the indications for secondary surgery after endoscopic puncture or partial nephrectomy? J Pediatr Urol 2013; 9:11-6. [PMID: 22819760 DOI: 10.1016/j.jpurol.2012.06.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/22/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We assessed outcomes and need for secondary surgery after primary trans-urethral puncture (TUP) or upper pole partial nephrectomy (UPPN) in duplex system ureterocele (DSU) patients undergoing management that disregards vesicoureteral reflux and upper pole function. SUBJECTS AND METHODS Between 2003 and 2010, 41 DSU <1 year underwent TUP (n = 32) or UPPN (n = 9). Postoperatively, additional investigations and surgery were limited to cases showing persistent hydroureteronephrosis or developing recurrent febrile urinary tract infections (UTI). Outcome parameters included upper tract decompression, UTI after decompression, continence status, and secondary surgery rate. Preoperative variables were compared between patients who required secondary surgery and those who did not. RESULTS Additional surgery was required for persistent hydroureteronephrosis in 20% of cases after TUP vs none after UPPN. After decompression, 4 female patients developed recurrent febrile UTI and 2 required additional surgeries. No case suffered from urinary incontinence. After a median (range) follow-up of 46 (17-102) months, TUP or UPPN was the only surgery required in 32 (78%) cases irrespective of preoperative variables. CONCLUSION UPPN seems more effective than TUP in decompressing severely dilated urinary tracts. After decompression, disregarding VUR status and upper pole function, TUP or UPPN is the only procedure required in 80% of DSU cases, regardless of preoperative variables.
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Parente A, Angulo J, Romero R, Rivas S, Tardáguila A, Corona C. [High-pressure balloon dilatation for treatment of orthotopic ureterocele]. Actas Urol Esp 2012; 36:117-20. [PMID: 21955558 DOI: 10.1016/j.acuro.2011.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 07/19/2011] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Transurethral puncture or endoscopic unroofing is the best treatment currently used for both orthotopic and ectopic ureteroceles. However, they have a high incidence of secondary vesicoureteral reflux and subsequent procedures in both groups. We present a new technique for treatment of orthotopic ureterocele. MATERIAL AND METHODS We have analyzed 4 patients with orthotopic ureterocele (9.7 ± 6.2 months old) treated by dilatation of the meatus of the ureterocele. No patient had vesicoureteral reflux or duplicate systems. The indication was pyonephrosis in 2 children and progressive worsening of hydronephrosis in 2. Dilatation was performed with 5 or 6mm high-pressure balloon after inserting a stent with guidewire of 0.014" to the ureterocele. RESULTS There were no intraoperative or postoperative complications, surgical time being 24 ± 9minutes. All patients were discharged at 24 postoperative hours. Ureterohydronephrosis disappeared in all the children and they continue asymptomatic after 35 ± 22.5 months of follow-up. There were no cases of secondary vesicoureteral reflux and renal scan was unchanged after treatment. CONCLUSIONS High pressure balloon dilatation of the meatus in cases of orthotopic ureterocele is a fast, safe and successful surgical technique. We did not find any cases of secondary vesicoureteral reflux or subsequent procedures in our series, so we believe this may offer significant benefits over the transurethral puncture in such patients.
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Recent advances in the management of ureteroceles in infants and children: why less may be more. Curr Opin Urol 2011; 21:322-7. [DOI: 10.1097/mou.0b013e328346d455] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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