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Salehi-Pourmehr H, Lotfi B, Mohammad-Rahimi M, Tahmasbi F. Surgical patterns in the endoscopic management of pediatric ureterocele: A systematic review and meta-analysis. J Pediatr Urol 2024:S1477-5131(24)00195-5. [PMID: 38705762 DOI: 10.1016/j.jpurol.2024.04.005] [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: 09/13/2023] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To assess the results of endoscopic ureterocele treatments as well as the effects of ureterocele location (intravesical vs. ectopic) and anatomy (single vs. duplicated system) on treatment outcomes. MATERIAL AND METHODS Following the Systematic Reviews and Meta-Analyses (PRISMA) standards, several medical databases as well as Google Scholar were searched comprehensively. Studies describing secondary operation outcomes for endoscopic transurethral incision and puncture were included. Studies were required to compare patients according to ureterocele location (intravesical or ectopic) and anatomy (single or duplex system) or preoperative reflux. Meta-analysis was conducted using Comprehensive Meta-analysis (CMA) software. RESULTS A total of 83 studies entered this systematic review consisting of 3022 patients. According to the meta-analysis of 16 studies, the risk ratio (RR) of reoperation after ureterocele incision was significantly higher in patients with ectopic vs. intravesical ureteroceles (RR: 2.42; 95% CI: 1.89-3.11; P < 0.001; I2: 14.89%). Also, a higher reoperation rate was reported in patients with duplex system ureteroceles (DSU) vs. single system ureteroceles (SSU) with little heterogeneity based on 9 studies. (RR: 2.50; 95% CI: 1.60-3.91; P < 0.001; I2: 13.83%). CONCLUSION Our results showed that ectopic ureteroceles and duplex systems are associated with higher reoperation rates after endoscopic procedures.
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Affiliation(s)
- Hanieh Salehi-Pourmehr
- Research Center for Evidence-based Medicine, Iranian EBM Centre: A JBI Centre of Excellence, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran; Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Behzad Lotfi
- Department of Urology, Tabriz University of Medical Sciences, Tabriz, Iran.
| | | | - Fateme Tahmasbi
- Research Center for Evidence-based Medicine, Iranian EBM Centre: A JBI Centre of Excellence, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Corona LE, Lai A, Meyer T, Rosoklija I, Berkowitz R, Liu D, Maizels M, Cheng EY, Lindgren BW, Chu DI, Johnson EK, Gong EM. Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes. J Pediatr Urol 2023; 19:85.e1-85.e8. [PMID: 37590379 DOI: 10.1016/j.jpurol.2022.09.024] [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: 06/30/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure). OBJECTIVE With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants. STUDY DESIGN A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups. RESULTS Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques. DISCUSSION RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers. CONCLUSIONS Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.
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Affiliation(s)
- Lauren E Corona
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Andrew Lai
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, University of Illinois at Chicago, Chicago, IL, 60612 USA.
| | - Theresa Meyer
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Ilina Rosoklija
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Rachel Berkowitz
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA.
| | - Dennis Liu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Max Maizels
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Earl Y Cheng
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Bruce W Lindgren
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - David I Chu
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Emilie K Johnson
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
| | - Edward M Gong
- Division of Urology, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611 USA; Department of Urology, Northwestern Feinberg School of Medicine, 420 E. Superior St. Chicago, Illinois, 60611 USA.
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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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Transurethral incision as initial option in treatment guidelines for ectopic ureteroceles associated with duplex systems. World J Urol 2019; 37:2237-2244. [DOI: 10.1007/s00345-018-2607-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/13/2018] [Indexed: 11/26/2022] Open
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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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Adorisio O, Elia A, Landi L, Taverna M, Malvasio V, Danti AD. Effectiveness of Primary Endoscopic Incision in Treatment of Ectopic Ureterocele Associated With Duplex System. Urology 2011; 77:191-4. [DOI: 10.1016/j.urology.2010.02.061] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 02/23/2010] [Accepted: 02/23/2010] [Indexed: 11/24/2022]
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Yoo E, Kim H, Chung S. Bladder surgery as first-line treatment of complete duplex system complicated with ureterocele. J Pediatr Urol 2007; 3:291-4. [PMID: 18947758 DOI: 10.1016/j.jpurol.2006.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Accepted: 10/30/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We retrospectively analyzed our experience to determine the optimum management of complete duplex system complicated with ureterocele. MATERIALS AND METHODS Between 1994 and 2003, we reviewed 15 patients treated with bladder surgery for complete duplex system complicated with ureterocele. The associated anomalies were seven vesicoureteral reflux (VUR) of the lower pole ureter and one of both poles. All patients had ureterocele (11 intravesical, 4 extravesical) and a functioning upper moiety. Initial treatment was transurethral incision of ureterocele (TUI) (14) or common sheath reimplantation (1). The median follow-up was 30 (13-48) months. RESULTS There were no requirements for secondary procedures, with a significant improvement or conservation of ipsilateral renal function and no reflux, in 10 patients (67%). Five patients (33%) with ureterocele (1 intravesical, 4 extravesical) who initially underwent TUI required additional operative management due to moderate to severe VUR, recurrent urinary tract infection or decreased function of upper moiety. The secondary operation performed was lower pole nephrectomy with ureteral reimplantation (1), ureteroureterostomy with ureteral reimplantation (2) or common sheath reimplantation (2). One patient who underwent common sheath reimplantation as secondary operation needed a nephrectomy due to breakthrough febrile urinary tract infection and decreased renal function. CONCLUSION TUI is recommended as the first-line treatment of complete duplex system with intravesical ureterocele and well-conserved renal function.
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Affiliation(s)
- Eunsang Yoo
- College of Medicine, Kyungpook National University, Republic of Korea
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Byun E, Merguerian PA. A Meta-Analysis of Surgical Practice Patterns in the Endoscopic Management of Ureteroceles. J Urol 2006; 176:1871-7; discussion 1877. [PMID: 16945677 DOI: 10.1016/s0022-5347(06)00601-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE We examined the contribution of patient features on reoperation after transurethral incision or puncture in children with ureteroceles. MATERIALS AND METHODS A systematic review was accomplished using Medline and article bibliographies to obtain articles related to endoscopic management of ureteroceles in English, Spanish, Italian, French and Japanese. Exposures of interest were ureterocele position and anatomy, and preoperative reflux. The outcome was secondary operation. Meta-analysis was done using Mantel-Haenszel calculations. RESULTS Meta-analysis of 10 studies demonstrated that ectopic ureteroceles are associated with significantly greater reoperation rates than intravesical ureteroceles in patients undergoing ureterocele incision. This remains true with longer followup and systematic ureterocele incision/puncture, in neonates and in patients with single and duplex collecting systems. In addition, a meta-analysis of 3 studies showed that patients with duplex system ureteroceles are more likely to require subsequent operation. A third meta-analysis of 7 studies showed that preoperative reflux increases the risk of reoperation after ureterocele incision. More than 1 risk factor did not appear to increase the risk of secondary operation. CONCLUSIONS To our knowledge this is the first systematic review of endoscopic ureterocele management. It suggests that ectopic ureterocele location, duplex renal systems and preoperative reflux are proxies for trigonal anatomical distortion, rather than independent risk factors for a secondary operation after incision. Findings reinforce the importance of considering these variables when making management decision in children with ureteroceles.
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Affiliation(s)
- Esther Byun
- University of California-San Francisco, San Francisco, CA, USA
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Jankowski JT, Palmer JS. Holmium: yttrium-aluminum-garnet laser puncture of ureteroceles in neonatal period. Urology 2006; 68:179-81. [PMID: 16806429 DOI: 10.1016/j.urology.2006.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 12/26/2005] [Accepted: 01/27/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The use of the holmium:yttrium-aluminum-garnet (YAG) laser to incise a ureterocele in children has been reported. However, its use to puncture ureteroceles in neonates has not. Therefore, we evaluated the effectiveness and safety of ureterocele puncture using a holmium-YAG laser in neonatal patients. METHODS We reviewed our experience of all neonates (ie, children younger than 28 days old) who underwent transurethral puncture of a ureterocele. The preoperative data collected included age at presentation, mode of presentation, ureterocele location, and weight and age at the procedure. A holmium:YAG laser was used to incise the ureterocele, and a 200, 365, or 550-microm laser fiber was passed through a 6F or 7.5F cystoscope. RESULTS A total of 4 neonates (2 boys and 2 girls) underwent transurethral holmium laser puncture of five ureteroceles. All patients were initially diagnosed with prenatal ultrasound findings confirmed after birth with additional imaging. The mean age at the initial puncture was 13.8 days, with a mean patient weight of 3.9 kg. The mean follow-up was 2.8 years (range 1.7 to 3.4). Four (80%) of five ureteroceles were adequately decompressed after one attempt. One patient required a second puncture of the ureterocele at 46 days of age because of incomplete decompression. None of the patients experienced an intraoperative or postoperative complication, including new vesicoureteral reflux after laser puncture. CONCLUSIONS Holmium:YAG laser puncture of ureterocele is a safe, efficacious, and viable option for children in the neonatal period. However, this technique in these young children requires additional evaluation.
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Affiliation(s)
- Jason T Jankowski
- Division of Pediatric Urology, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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Ziylan O, Oktar T, Korgali E, Nane I, Alp T, Ander H. Lower Urinary Tract Reconstruction in Ectopic Ureteroceles. Urol Int 2005; 74:123-6. [PMID: 15756063 DOI: 10.1159/000083282] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2004] [Accepted: 10/28/2004] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The management of ectopic ureteroceles is a challenging entity in pediatric urology. In our study, we aimed to determine the outcome after lower urinary tract reconstruction in ectopic ureteroceles. MATERIALS AND METHODS A total of 18 (12 girls, 6 boys) children with ectopic ureteroceles, treated between 1993 and 2003 by complete reconstruction, were enrolled in the study and their records were retrospectively reviewed. RESULTS Ureterocele was found to be unilateral in 16 and bilateral in 2 children. Four patients had been previously managed by endoscopic interventions and 1 patient underwent partial nephrectomy. Ureterocelectomy was performed on 20 renal units, and of these 20 renal units, 9 underwent heminephroureterectomy, 1 ureterectomy, and 3 (with single system ureteroceles) nephroureterectomy. Seven (35%) renal units with adequate function underwent ureteral reimplantations. After a mean follow-up of 5.4 years (range 4 months to 9.5 years), no patient required a second procedure. Contralateral reflux that developed in 2 children after surgical treatment resolved spontaneously after 1 year of follow-up. CONCLUSION In the management of ectopic ureterocele, lower urinary tract reconstruction is an effective treatment alternative. According to the functional status of the renal parenchyma involved, the surgical procedure was limited to the lower urinary tract in 35% of the cases.
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Affiliation(s)
- Orhan Ziylan
- Division of Pediatric Urology, Department of Urology, Istanbul Faculty of Medicine, University of Istanbul, Istanbul, Turkey.
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Castagnetti M, Cimador M, Sergio M, de Grazia E. Transurethral incision of duplex system ureteroceles in neonates: does it increase the need for secondary surgery in intravesical and ectopic cases? BJU Int 2004; 93:1313-7. [PMID: 15180630 DOI: 10.1111/j.1464-410x.2004.04861.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the relevance of ureterocele ectopia and associated reflux on the outcome of duplex system ureteroceles (DSU) after neonatal transurethral incision (TUI). PATIENTS AND METHODS The study included 41 neonates with a diagnosis of DSU; the ureterocele was ectopic in 24 (58%). Before TUI, vesico-ureteric reflux (VUR) was present in 13 lower moieties (32%) and seven contralateral ureters (17%). TUI was always performed within the first month of life. The follow-up and management were tailored for each patient from the findings at ultrasonography, voiding cysto-urethrography and renal scintigraphy. Results of intravesical and ectopic DSU were compared using Fisher's exact test. RESULTS TUI was effective in allowing ureteric decompression in all but one patient (2.4%). After TUI, VUR ceased in six lower ipsilateral moieties and in two contralateral ureters, while new VUR occurred in three contralateral kidneys. De novo VUR in the punctured moiety appeared in 13 cases (32%). Nine upper poles were not functioning. Twenty-one patients (51%) required secondary surgery. Ureteric reimplantation was indicated exclusively for reflux in the punctured moiety in only in two cases (5%), while in a further two iatrogenic reflux in a nonfunctioning upper moiety required total heminephro-ureterectomy. There was no significant difference between intravesical and ectopic ureteroceles in the occurrence of VUR in the punctured moiety, rate of nonfunctioning upper poles or need for secondary surgery. CONCLUSIONS About half of the patients with a DSU need secondary surgery, but this is rarely indicated for de novo reflux in the punctured moiety only. The need for secondary surgery was greater whenever there was associated reflux before endoscopic incision. There was no difference in the outcome of intravesical and ectopic ureteroceles and such distinction seems no longer to be of clinical relevance.
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Affiliation(s)
- M Castagnetti
- E. Albanese Hospital, Paediatric Surgery Unit, University of Palermo, Palermo, Italy.
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DeFoor W, Minevich E, Tackett L, Yasar U, Wacksman J, Sheldon C. Ectopic ureterocele: clinical application of classification based on renal unit jeopardy. J Urol 2003; 169:1092-4. [PMID: 12576859 DOI: 10.1097/01.ju.0000049246.53911.04] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The Churchill classification system grades the ectopic ureterocele based on the number of renal units in jeopardy. We apply this system to our experience to help predict response to initial surgical intervention. MATERIALS AND METHODS All cases of ectopic ureterocele diagnosed at our institution between 1990 and 2000 were retrospectively reviewed and categorized using the Churchill classification system. Initial surgical procedure and subsequent outcomes were analyzed. RESULTS A total of 53 patients were identified, of whom 42% had only upper pole involvement (grade I), 40% ipsilateral upper and lower pole involvement (grade II) and 19% bilateral renal involvement (grade III). Endoscopic incision was definitive in 56% of grade I, 20% of grade II and no grade III ureteroceles. An upper tract approach was definitive in 85% of grade I, 45% of grade II and no grade III ureteroceles. An initial lower tract procedure was successful in 80% of grade II and 100% of grade III ureteroceles. Overall the initial surgical procedure was definitive in 73% of grade I, 48% of grade II and 20% of grade III ureteroceles. CONCLUSIONS Our results confirm the findings of Churchill. In this series the majority of grade I ureteroceles were successfully managed with an upper tract procedure. However, high grade ureteroceles were more likely to require a secondary operation unless an initial lower tract reconstruction was performed.
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Affiliation(s)
- William DeFoor
- Division of Pediatric Urology, Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA
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Affiliation(s)
- A A Shokeir
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Bolduc S, Upadhyay J, Sherman C, Farhat W, Bagli DJ, McLorie GA, Khoury AE, El-Ghoneimi A. Histology of upper pole is unaffected by prenatal diagnosis in duplex system ureteroceles. J Urol 2002; 168:1123-6. [PMID: 12187250 DOI: 10.1016/s0022-5347(05)64606-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE We determined whether the histology of upper pole nephrectomy specimens vary with prenatal detection or ureterocele position. MATERIALS AND METHODS Between 1992 and 2000, 95 patients with ureteroceles associated with a duplex system underwent surgical interventions, including upper pole nephrectomy in 60. A total of 55 specimens, of which 25 and 30 involved a prenatal and postnatal diagnosis, and 18 and 37 involved an intravesical and extravesical location, respectively, were available for independent review by a single pathologist. Histological lesions were classified into the 5 categories of chronic interstitial inflammation, fibrosis, tubular atrophy, glomerulosclerosis and dysplasia. Each category was divided into moderate/severe histological lesions (greater than 25% involvement) and minimal/mild lesions (25% or less involvement). RESULTS A moderate/severe histological lesion was identified in 38 patients (69%) and a minimal/mild lesion was detected in 17 (31%), while dysplasia was present in 35 (64%). There was no significant difference in histological lesions and mode of presentation. In contrast to intravesical ureteroceles, extravesical ureteroceles were associated with severe fibrosis and tubular atrophy (p <0.05). Chronic interstitial inflammation, fibrosis, tubular atrophy and glomerulosclerosis in each specimen were graded moderate/severe (greater than 25% involved) in 55%, 67%, 66% and 53%, respectively. CONCLUSIONS Prenatally diagnosed ureteroceles were not associated with less severe upper pole histological lesions. We noted pathological differences when comparing specimens according to ureterocele position, but chronic inflammation and dysplasia were similar in intravesical and extravesical ureterocele cases. It appears that the histological lesions observed are not progressive or reversible. Therefore, the goals of clinical management should focus on providing adequate drainage, antibiotic prophylaxis coverage and followup of reflux rather than the preservation or enhancement of upper pole function.
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IS ENDOSCOPIC DECOMPRESSION OF THE NEONATAL EXTRAVESICAL UPPER POLE URETEROCELE NECESSARY FOR PREVENTION OF URINARY TRACT INFECTIONS OR BLADDER NECK OBSTRUCTION? J Urol 2002. [DOI: 10.1097/00005392-200203000-00074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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IS ENDOSCOPIC DECOMPRESSION OF THE NEONATAL EXTRAVESICAL UPPER POLE URETEROCELE NECESSARY FOR PREVENTION OF URINARY TRACT INFECTIONS OR BLADDER NECK OBSTRUCTION? J Urol 2002. [DOI: 10.1016/s0022-5347(05)65339-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Affiliation(s)
- LANCE MARR
- From the Division of Urology, Oregon Health Sciences University, Portland, Oregon
| | - STEVEN J. SKOOG
- From the Division of Urology, Oregon Health Sciences University, Portland, Oregon
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Somoza Argibay I, Méndez Gallart R, Gómez Tellado M, Pais Piñeiro E, Liras Muñoz J, Vázquez Martull E, Vela Nieto D. [Treatment of pyeloureteral duplication associated with ureterocele or ectopic ureter]. Actas Urol Esp 2001; 25:731-6. [PMID: 11803780 DOI: 10.1016/s0210-4806(01)72709-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Pyeloureteral duplication is often associated to ureterocele and ectopic ureter. Therapeutic approach of ureterocele is actually a debated subject because of the differences treatments. There is controversy about the classic heminefrectomy with ureterocele aspiration and the minimal invasive endoscopic approach. MATERIAL AND METHODS We made a retrospective study about 34 children with pyeloureteral duplication associated with ureterocele (26) or with ectopic ureter (8). The election of treatment was mainly based on renal function, showed on gammagraphy. It was performed heminephrectomy and ureterocele aspiration in patients with hypofunctioning upperpole, and surgery saving the kidney when the renal function was normal. RESULTS Heminephrectomy was curative in 66.5% of children with ureterocele. In the others was required a correction of the vesicoureteral reflux associated with the lower pole or removal of the ureterocele with ureteral reimplantation due to failure in ureterocele collapse. 88.5% of ureterocele was collapsed. None of the heminefrectomies performed on patients with ectopic ureter needed further surgery. Pathology studies showed a high incidence of renal dysplasia (63%). CONCLUSION We consider the heminephrectomy the treatment of choice in pyeloureteral duplication associated with ureterocele and ectopic ureter when gammagraphy studies show hypofunctioning upperpole.
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Affiliation(s)
- I Somoza Argibay
- Servicio de Cirugía Pediátrica, Hospital Materno Infantil Teresa Herrera, Complejo Hospitalario Juan Canalejo, A Coruña
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Decter RM, Sprunger JK, Holland RJ. Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele? J Urol 2001; 165:2308-10. [PMID: 11371968 DOI: 10.1097/00005392-200106001-00023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE During the last 10 years we attempted to treat most children presenting with a ureterocele with a single definitive operative procedure. We reviewed the surgical results to assess the success of the preoperative plan in achieving this outcome. MATERIALS AND METHODS We retrospectively reviewed the records and diagnostic studies of all children who underwent surgery for a ureterocele during the last 10 years at our institution. The intent of the surgeon as to whether the procedure was intended to be definitive was stated in the clinic notes in all cases. RESULTS Surgery for a ureterocele was performed in 38 children during the study period. Transurethral incision was used in 7 patients and, although it was intended to be definitive in 2, all 7 required subsequent surgery for vesicoureteral reflux. Isolated upper tract surgery was performed with intent to cure in 20 of 21 patients including upper pole heminephrectomy in 17 and upper to lower ureteroureterostomy in 3. Of the 20 patients initially treated with this simplified approach 17 (85%) did not require subsequent surgery for ureterocele and 12 had vesicoureteral reflux preoperatively, which persisted in 2 (10%) and required subsequent surgery in 3 (15%). Total reconstruction of the ureterocele was performed in 10 patients and 1 of whom required subsequent surgery. We achieved resolution of all problematic aspects of the ureterocele with a single procedure in 26 of 32 patients (81%). CONCLUSIONS A single procedure that definitively treats all problems of a ureterocele can be selected in more than three-quarters of patients. Transurethral incision was unsuccessful at definitively treating these patients in our experience. An isolated upper tract procedure was successful in patients with no or mild associated vesicoureteral reflux. We think that upper tract surgery should be the procedure of choice in this subset of patients, as it usually resolves the problem and does not subject the patient to the potential morbidities of bladder surgery. Although total reconstruction is a more formidable procedure, it can be performed safely with excellent results.
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Affiliation(s)
- R M Decter
- Section of Urology, Department of Surgery, Milton S. Hershey Medical Center of Pennsylvania State University, Hershey, Pennsylvania, USA
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Decter RM, Sprunger JK, Holland RJ. Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele? J Urol 2001; 165:2308-10. [PMID: 11371968 DOI: 10.1016/s0022-5347(05)66191-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE During the last 10 years we attempted to treat most children presenting with a ureterocele with a single definitive operative procedure. We reviewed the surgical results to assess the success of the preoperative plan in achieving this outcome. MATERIALS AND METHODS We retrospectively reviewed the records and diagnostic studies of all children who underwent surgery for a ureterocele during the last 10 years at our institution. The intent of the surgeon as to whether the procedure was intended to be definitive was stated in the clinic notes in all cases. RESULTS Surgery for a ureterocele was performed in 38 children during the study period. Transurethral incision was used in 7 patients and, although it was intended to be definitive in 2, all 7 required subsequent surgery for vesicoureteral reflux. Isolated upper tract surgery was performed with intent to cure in 20 of 21 patients including upper pole heminephrectomy in 17 and upper to lower ureteroureterostomy in 3. Of the 20 patients initially treated with this simplified approach 17 (85%) did not require subsequent surgery for ureterocele and 12 had vesicoureteral reflux preoperatively, which persisted in 2 (10%) and required subsequent surgery in 3 (15%). Total reconstruction of the ureterocele was performed in 10 patients and 1 of whom required subsequent surgery. We achieved resolution of all problematic aspects of the ureterocele with a single procedure in 26 of 32 patients (81%). CONCLUSIONS A single procedure that definitively treats all problems of a ureterocele can be selected in more than three-quarters of patients. Transurethral incision was unsuccessful at definitively treating these patients in our experience. An isolated upper tract procedure was successful in patients with no or mild associated vesicoureteral reflux. We think that upper tract surgery should be the procedure of choice in this subset of patients, as it usually resolves the problem and does not subject the patient to the potential morbidities of bladder surgery. Although total reconstruction is a more formidable procedure, it can be performed safely with excellent results.
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Affiliation(s)
- R M Decter
- Section of Urology, Department of Surgery, Milton S. Hershey Medical Center of Pennsylvania State University, Hershey, Pennsylvania, USA
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Abstract
Ureteroceles are potentially complex anomalies that have historically been managed with open reconstructive operations. In the last decade, endoscopic management has been proposed as an initial approach in patients with ureteroceles. With antenatal diagnosis, intervention can be performed on an outpatient basis prior to the development of any infections. Recent peer-reviewed studies help to define the appropriate technique, the patient population best managed with incision, and long-term outcomes.
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Affiliation(s)
- D E Coplen
- Division of Pediatric Urology, Washington University School of Medicine and St. Louis Children"s Hospital, One Children's Place, St. Louis, MO 63110, USA.
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Affiliation(s)
- D E Coplen
- St. Louis Children's Hospital, St. Louis, Missouri, USA
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Cooper CS, Passerini-Glazel G, Hutcheson JC, Iafrate M, Camuffo C, Milani C, Snyder HM. Long-term followup of endoscopic incision of ureteroceles: intravesical versus extravesical. J Urol 2000; 164:1097-9; discussion 1099-100. [PMID: 10958751 DOI: 10.1097/00005392-200009020-00045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Endoscopic incision was performed as the initial therapy for ureteroceles in children presenting to our institutions between 1985 and 1990. To assess the long-term efficacy of this treatment modality we reevaluated the outcome of these patients. MATERIALS AND METHODS Parameters reviewed included patient age at surgery, position of the ureterocele, a duplex system, preoperative and postoperative reflux, and the need for additional operations. Statistical analysis consisted of chi-square and Wilcoxon's rank sum tests. RESULTS Of the patients 22 had intravesical and 22 had extravesical ureteroceles. Average age at initial surgery was 1.9 +/- 3.7 years with average followup of 7.2 +/- 3.1 years. A second operation was required in 18 cases (41%), which was significantly more likely for an extravesical ureterocele (18% versus 64%, p = 0. 002), a duplex system (p = 0.026) or preoperative reflux (p = 0.02). Second operations included reimplantation in 13 cases, upper pole partial nephrectomy in 7, total nephroureterectomy in 3, bladder neck reconstruction in 3 and lower pole pyeloplasty in 3. The only secondary operations performed for intravesical ureteroceles were reimplantation in 3 cases and upper pole nephrectomy in 1. New onset reflux developed in 14 of 27 patients (52%) postoperatively, including 7 with intravesical and 7 with extravesical ureteroceles. None required a second open operation. CONCLUSIONS With extended followup the percentage of patients requiring open surgery after endoscopic incision of ureteroceles increased from our original report of 27% to 41% (p = 0.166). Only 18% of cases with an intravesical ureterocele required a subsequent operation compared to 64% with an extravesical ureterocele (p = 0.002). The reduction in size of the obstructed ureter following endoscopic decompression facilitated successful reimplantation. Endoscopic puncture permits definitive treatment in the majority of children by at most a single incision, open operation at the bladder level.
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Affiliation(s)
- C S Cooper
- Division of Pediatric Urology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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HAGG MICHAELJ, MOURACHOV PAVELV, SNYDER HOWARDM, CANNING DOUGLASA, KENNEDY WILLIAMA, ZDERIC STEVENA, DUCKETT JOHNW. THE MODERN ENDOSCOPIC APPROACH TO URETEROCELE. J Urol 2000. [DOI: 10.1016/s0022-5347(05)67857-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- MICHAEL J. HAGG
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - PAVEL V. MOURACHOV
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - HOWARD M. SNYDER
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - DOUGLAS A. CANNING
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - WILLIAM A. KENNEDY
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - STEVEN A. ZDERIC
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - JOHN W. DUCKETT
- From the Division of Urology, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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HUSMANN DOUGLAS, STRAND BILL, EWALT DAVID, CLEMENT MICHELE, KRAMER STEVE, ALLEN TERRY. MANAGEMENT OF ECTOPIC URETEROCELE ASSOCIATED WITH RENAL DUPLICATION: A COMPARISON OF PARTIAL NEPHRECTOMY AND ENDOSCOPIC DECOMPRESSION. J Urol 1999. [DOI: 10.1016/s0022-5347(05)68322-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- DOUGLAS HUSMANN
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - BILL STRAND
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - DAVID EWALT
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - MICHELE CLEMENT
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - STEVE KRAMER
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
| | - TERRY ALLEN
- From the Mayo Clinic, Rochester, Minnesota, and University of Texas Southwestern and Children's Medical Center, Dallas, Texas
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MANAGEMENT OF ECTOPIC URETEROCELE ASSOCIATED WITH RENAL DUPLICATION: A COMPARISON OF PARTIAL NEPHRECTOMY AND ENDOSCOPIC DECOMPRESSION. J Urol 1999. [DOI: 10.1097/00005392-199910000-00066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shekarriz B, Upadhyay J, Fleming P, González R, Barthold JS. Long-term outcome based on the initial surgical approach to ureterocele. J Urol 1999; 162:1072-6. [PMID: 10458434 DOI: 10.1016/s0022-5347(01)68071-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele. MATERIALS AND METHODS We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery. RESULTS Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months). CONCLUSIONS Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.
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Affiliation(s)
- B Shekarriz
- Department of Urology, Children's Hospital of Michigan, Wayne State University, Detroit, USA
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Shekarriz B, Upadhyay J, Fleming P, González R, Barthold JS. Long-term outcome based on the initial surgical approach to ureterocele. J Urol 1999; 162:1072-6. [PMID: 10458434 DOI: 10.1097/00005392-199909000-00033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele. MATERIALS AND METHODS We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery. RESULTS Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months). CONCLUSIONS Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.
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Affiliation(s)
- B Shekarriz
- Department of Urology, Children's Hospital of Michigan, Wayne State University, Detroit, USA
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Petit T, Ravasse P, Delmas P. Does the endoscopic incision of ureteroceles reduce the indications for partial nephrectomy? BJU Int 1999; 83:675-8. [PMID: 10233578 DOI: 10.1046/j.1464-410x.1999.00008.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether the endoscopic incision of ureteroceles reduces the indications for partial nephrectomy. PATIENTS AND METHODS Between 1987 and 1996, endoscopic incision was used as the first-line treatment of 18 children (13 boys, five girls, aged 8 days to 6 months) with a duplex-system ureterocele diagnosed antenatally (15) or in the first weeks of life during the course of a urinary infection (three). Of the 19 ureteroceles (one bilateral), four were intravesical and 15 ectopic, according to the American Academy of Paediatrics classification. Vesico-ureteric reflux into the inferior pole of the kidney was present in 10 children, seven of whom had an ectopic ureterocele. A functioning upper pole was detected by intravenous pyelography (IVP) in half the intravesical and in a third of the ectopic ureteroceles. RESULTS Endoscopic incision resulted in decompression and reduction of dilatation in 16 cases; three with inferior pole reflux resolved on control cystography, whilst in seven with an ectopic ureterocele, reflux into the upper urinary tract was induced by endoscopic incision. In three children with an ectopic ureterocele, renal function had improved at 3 months, as assessed by IVP. Endoscopic incision was the only treatment for half the intravesical and six of 15 ectopic ureteroceles. Overall, nephrectomy was required in four of 18 patients (three partial nephrectomies for persistent dilatation and one total nephrectomy). Five nonfunctioning, undilated upper poles with no reflux were left in place. Nine vesico-ureteric reimplantations for persistent or induced reflux were carried out using the Cohen technique. CONCLUSION Endoscopic incision can allow the deferral of nephrectomy, facilitate lower urinary tract reconstruction and reduce the indications for partial nephrectomy, if it is accepted that a nonfunctioning, undilated renal pole with no reflux can safely be left in place.
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Affiliation(s)
- T Petit
- Department of Paediatric Surgery, Caen University Hospital, Caen, France
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Abstract
OBJECTIVES To determine if prenatal identification of significant renal duplication anomalies affects the management of the patient or the clinical outcome. METHODS This is a retrospective review of 79 consecutive children with severe hydronephrosis involving a duplex renal collecting system, identified by either prenatal ultrasound (asymptomatic), or symptoms, most often urinary tract infection, but also including abdominal mass, hematuria, or incontinence. An individualized combination of voiding cystourethrogram, ultrasound, intravenous urogram, and nuclear renal scan was used to assess anatomy and function. Ablation of the involved segment was carried out if no or extremely poor function was identified; a definitive reconstructive procedure was elected in the face of easily measureable function. Outcome was determined clinically and by repeat imaging. RESULTS There was no difference in the rate of renal segment salvage between the prenatally and clinically diagnosed groups. Of the cases analyzed, 20/79 were prenatally identified, of which 13/20 (65%) were reconstructed; 59/79 were identified on clinical grounds, of which 34/59 (58%) were reconstructed. One patient in the prenatal salvage group underwent removal of the affected kidney 5 years later. Another, in the clinical salvage group, underwent a successful secondary procedure for closure of a ureteral fistula. All others have shown improved function, drainage, or both in follow-up. No secondary procedures have been required for the ablation group to date. Follow-up ranges from 4 months to 12 years. CONCLUSIONS Prenatal identification of significant duplex system hydronephrosis does not improve the rate of renal segment salvage, as determined by standard radiographic means, compared to later identification on clinical grounds. The decision for reconstruction versus ablation in significant duplex system hydronephrosis can be made on the basis of function alone.
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Affiliation(s)
- W C Hulbert
- Department of Urology, University of Rochester Medical Center, New York 14642-8656, USA
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Abstract
As many as 1% of newborn infants have a prenatal diagnosis of hydronephrosis or significant renal pelvic dilation. Hydronephrosis often is caused by nonobstructive conditions. The likelihood of significant urologic pathology is directly related to the size of the fetal renal pelvis, and 90% with an anteroposterior diameter more than 2 cm need surgery or long-term urologic medical care. Following delivery, antibiotic prophylaxis should be administered and a renal sonogram and voiding cystourethrogram should be obtained. If there is grade 3 or 4 hydronephrosis, usually a diuretic renogram is recommended also. Pediatric urologic or pediatric nephrologic consultation usually is helpful in planing evaluation and treatment. Prenatal recognition of hydronephrosis allows neonatal diagnosis and treatment of urologic pathology, preventing complications of pyelonephritis and obstruction.
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Affiliation(s)
- J S Elder
- Department of Urology and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Abstract
Renal duplications and fusion anomalies in children often present challenging problems. The diagnostic evolution of these entities often consists of upper tract imaging to evaluate function and help diagnose obstruction, and lower tract imaging to assess reflux and at times voiding dynamics. The clinician needs to be aware of the variable presentations of these lesions, their evolution, and the therapeutic interventions that may be required to resolve problems resulting from them.
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Affiliation(s)
- R M Decter
- Department of Pediatric Urology, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, USA
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Di Benedetto V, Morrison-Lacombe G, Bagnara V, Monfort G. Transurethral puncture of ureterocele associated with single collecting system in neonates. J Pediatr Surg 1997; 32:1325-7. [PMID: 9314254 DOI: 10.1016/s0022-3468(97)90313-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE It is believed by some investigators that transurethral puncture (TUP) of single-system intravesical ureterocele (SSU) is the treatment of choice in totally asymptomatic patients who receive this diagnosis in utero, but its success depends on the incision technique and type of the uroterocele incised. METHODS Experience with 20 SSU in 17 asymptomatic newborns detected by prenatal ultrasound scan is reviewed. TUP of the SSU was performed as treatment of choice in 12 (60%) renal units (RU). RESULTS Decompression of the ureterocele was achieved in 100% of cases, and a vesicoureteral reflux was created in three (25%) RU. Surgery was performed in only 30% of patients who underwent TUP of the ureterocele. Our experience confirms that short (2 to 3 mm) TUP achieves decompression of the affected renal unit and that this procedure can be performed in neonates as outpatient procedure. In addition, it is often the only procedure to perform. CONCLUSION The authors believe that TUP should be considered the treatment of choice in the management of single-system ureteroceles.
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Affiliation(s)
- V Di Benedetto
- Department of Pediatric Surgery, St Joseph Hospital, Marseille, France
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Abstract
The treatment of ureteroceles in children requires an individualised approach. Antenatal diagnosis is the ideal, so that postnatal urinary antibiotic prophylaxis and appropriate investigations can be organised. Postnatal investigations should assess both upper and lower urinary tract. Renal and bladder ultrasound and radiographic micturating cystourethragraphy under antibiotic cover will both detect vesicoureteric reflux and assess any bladder outlet obstruction due to the ureterocele. Renal function, particularly of the upper moiety, is best evaluated by technetium Tc99m dimercaptosuccinic acid renal scan. Both function and obstruction can be quantitated by the Tc99m-mercaptoacetyltriglycine isotope scan with intravenous volume expansion (10 ml/kg) and furosemide diuresis (1 mg/kg). Intravenous urography provides the best anatomic information when the upper moiety is functional. The surgical management is based on the clinical situation, which is often variable, and therefore needs to be tailored for each patient. The general principles include restoration of anatomy to as near normal as possible and preservation of functional renal tissue.
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Affiliation(s)
- G T Roy
- Department of Paediatric Surgery, Westmead Centre, Sydney, NSW, Australia
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