Individualized treatment of ureteroceles

Is lower urinary tract surgery without upper pole heminephrectomy safe and effective in the long-term treatment of duplex system ureterocele?

Objective:

The study aimed to retrospectively evaluate postoperative results of patients with duplex system ureterocele (DSU) who underwent endoscopic ureterocele incision (UI), lower urinary tract reconstruction (LUTR) or both, and investigate the necessity of upper pole heminephrectomy (UPH) in ureterocele treatment.

Patients and methods:

In total, 44 patients with DSU who were operated on in December 2005 and December 2018 were evaluated for patient characteristics, ureterocele location, differential renal function (DRF), vesicoureteral reflux (VUR), postoperative incontinence, proteinuria, hypertension and urinary tract infection (UTI).

Results:

UI was performed in 27 of 44 cases (61.3%) as the first-line treatment. Ten of them (37%) had no urinary infection or renal function loss at a mean of 3 years (1.5–7 years). LUTR was needed in 17 patients after UI due to VUR in 14 patients and bladder outlet obstruction (BOO) in 3 patients. In total, 34 patients who underwent LUTR, proteinuria or incontinence were not detected in the mean 6 years’ follow-up. Thirty-three patients (97%) had identical renal scans and similar DRF before and after the operation. No patient underwent UPH.

Conclusion:

UI must be considered the first-line treatment in DSU in infancy. In older patients, especially with VUR, LUTR is effective and safe and UPH mostly is not necessary.

Level of evidence:

4

Evaluating Outcomes of Differential Surgical Management of Nonfunctioning Upper Pole Renal Moieties in Duplex Collecting Systems

OBJECTIVE

To evaluate the management and clinical outcomes of nonfunctioning upper pole moieties treated with either upper pole heminephrectomy or upper pole preservation with lower ureteral reconstruction at a single tertiary institution.

METHODS

After Institutional Review Board (IRB) approval, patients with duplicated systems undergoing upper pole heminephrectomy, ureteroureterostomy, or common sheath ureteral reimplantation from 2012-2017 were identified. Only patients with a nonfunctioning upper pole moiety on ultrasound or renal scan were included. Patients undergoing upper pole heminephrectomy were compared to those undergoing upper pole preservation with respect to demographics, anatomic variations preoperatively, and postoperative outcomes.

RESULTS

Twenty-seven (57%) patients underwent upper pole preservation with lower ureteral reconstruction; 20 (43%) patients underwent upper pole heminephrectomy. Patients undergoing lower ureteral reconstruction were older (1.63 vs 2.76 years, P = .018) and more commonly presented with lower pole vesicoureteral reflux (67% vs 25%, P = .008). No significant difference in postoperative complications was seen between the two groups. After ureteroureterostomy, one patient developed new onset symptomatic reflux to the upper pole requiring intravesical reimplantation. In the heminephrectomy group, 4 of 11 patients with ureteroceles had ureterocelectomy with concomitant lower pole reimplantation. After heminephrectomy, two additional patients required further interventions: ureterocele excision and transurethral polyp excision.

CONCLUSION

For patients with nonfunctional upper poles, lower tract reconstruction is a safe alternative to upper pole heminephrectomy. No significant difference in outcomes was seen. Considering that nearly 1 of 3 of patients with upper pole heminephrectomy required additional lower urinary tract procedures, pursuing upper pole preservation with lower urinary tract reconstruction may be favorable.

Management of complicated ureteroceles: Different modalities of treatment and long-term outcome

The presentation and management of ureterocele has been rarely reported from India and is limited to an odd case report. They can be detected antenatally, may have incidental diagnosis or present with consequences of obstructive uropathy. They always present with secondary complications in adulthood, if the diagnosis and treatment is missed in early years of life. The natural history may be particularly disastrous in cases of bilateral obstructing ureterocele. The complications secondary to obstructive ureterocele can be urinary retention, pyonephrosis, urosepsis, stones and even chronic renal failure. Each of these patients needs an individualized treatment plan. In the period 2003-2013, we managed 36 consecutive patients with varied presentation of this entity. All were managed on the basis of a fixed protocol of investigation and operative intervention. Ultrasound, micturating cystourethrogram, isotope renogram were done preoperatively in all the babies. Those with asymptomatic, unobstructed ureteroceles were left without any intervention. Simple or complex intravesical ureteroceles underwent examination under anesthesia and endoscopic deroofing and DJ stenting for 3 weeks. Of a total of 36 children, 6 were presented with acute complications of ureterocele. They have been managed on an individualized optimum management plan. Their management approach with follow-up is being reported as there is no previous reported series on ureterocele in children from our country.

Outcomes of endoscopic incision for the treatment of ureterocele in children at a single institution

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.

Ureteroureterostomy irrespective of ureteral size or upper pole function: a single center experience

OBJECTIVE

Although ureteroureterostomy (UU) is an established procedure for the treatment of duplex anomalies, there may be a reluctance to apply this approach to patients with poor upper pole function and/or marked degrees of ureteral dilation.

METHODS

An institutional review board (IRB)-approved retrospective analysis of all patients undergoing UU between 2006 and present was performed. All patients underwent an end-to-side anastomosis with a double-J stent left in the lower pole ureter. Laparoscopic repairs were done 'high' and open repairs were done 'low'. If the upper pole ureter remained massively dilated after transection, the ureter was partially closed to reduce the length of the anastomosis. Data collected included demographics, diagnosis, surgical interventions, imaging studies and outcomes.

RESULTS

A total of 41 patients (43 renal units) were identified. There were 35 females and six males with an average age at surgery of 2.3 years (range 55 days to 15.9 years) and an average follow up of 2.8 years. Diagnosis included ureterocele (17), ectopic duplex ureter (25) and ureteral triplication (1). Thirty-six patients underwent UU only and five underwent UU with simultaneous lower pole reimplantation. Twelve of the 41 patients (29%) underwent laparoscopic repair. Twelve of the 43 renal units (28%) required ureteral tapering, of which three were performed laparoscopically. Preoperative median upper pole function was 17% (0-35%). Six patients had no measurable function and ten had < 15%. No patient developed lower pole hydronephrosis in the follow-up period. There were two complications: one patient was found to have a post-operative ureterovesical junction (UVJ) stricture and the second had an anastomotic stricture.

CONCLUSION

Ureteroureterostomy is a safe and effective technique for the reconstruction of duplex anomalies, even with a massively dilated and poorly functioning upper pole moiety. With no identifiable negative effect on the lower pole system, the concept of automatically removing 'dysplastic' upper pole segments can be challenged.

Management of duplex-system ureterocele

AIM

To analyse different treatment modalities, functional outcome and continence in children treated for duplex-system ureterocele and to review the relevant literature.

METHODS

The medical records of patients with duplex-system ureterocele treated between 2001 and 2011 were reviewed retrospectively.

RESULTS

Twenty-two cases were identified. Five patients underwent incision of the ureterocele as initial procedure. It was curative in only one patient. Seven patients underwent upper-pole nephroureterectomy. It was curative in 4 cases. Five patients underwent excision of ureterocele and common-sheath reimplant, and the remaining 5 patients had upper-pole nephroureterectomy and simultaneous excision of ureterocele with lower-moiety ureteric reimplantation. These surgeries were curative in all patients. Follow-up ranged from 4 to 84 months. Functional outcome was good in all patients. Fourteen patients were continent at follow-up, and continence was not assessed in the other 8 because of young age.

CONCLUSIONS

Our data suggest a higher rate of secondary procedures if there is retained ureterocele. Data also suggest that complete reconstruction can be safely performed in a young infant without any adverse effect on continence.

Ipsilateral Ureteroureterostomy in the Surgical Management of the Severely Dilated Ureter in Ureteral Duplication

PURPOSE

Ipsilateral ureteroureterostomy for the surgical management of severely dilated ureter in ureteral duplication is well supported in the surgical literature but often not done. We evaluated our institutional experience with ureteroureterostomy in duplication anomalies to assess the feasibility and success of this procedure.

MATERIALS AND METHODS

An 8-year retrospective review of the records of all patients with complete renal duplex anomalies was evaluated. Anatomical presentations, and operative and nonoperative treatment of these patients were evaluated.

RESULTS

A total of 193 patients were identified with complete renal duplication. Associated anomalies included ureterocele in 24 patients, ectopic ureter in 38 and vesicoureteral reflux in 57. Of 193 patients 160 (83%) with duplex anomalies underwent surgical intervention with a total of 41 ureteroureterostomies performed in 39 patients with dilated donor ureters. A total of 11 ureteroureterostomies were performed primarily and 30 were performed in conjunction with ipsilateral ureteral reimplantation of the distal common segment below the ureteroureterostomy. Ten of the 39 patients had the contralateral side reimplanted for vesicoureteral reflux. In all children with ureteroureterostomy the anastomosis between the 2 ureters remained patent. Two of the 11 children who underwent ureteroureterostomy alone had de novo ipsilateral vesicoureteral reflux (1), which was treated with ureteral reimplantation, and subureteral injection (1). Two children who underwent concomitant ureteroureterostomy and reimplantation without indwelling stents had transient postoperative urinomas that required subsequent drainage. Additionally, 3 patients had persistent ipsilateral vesicoureteral reflux, which was treated with subureteral injection in 1 and observation in 2. One patient presented with transient ipsilateral urinary obstruction, which required percutaneous drainage and resolved spontaneously.

CONCLUSIONS

In cases of ureteral duplication with a severely dilated ureter requiring surgical intervention ipsilateral ureteroureterostomy is a viable option for reflux and/or obstruction. The procedure is rapid and technically feasible, and it offers excellent cosmesis. In addition, ureteroureterostomy has minimal morbidity and it facilitates early hospital discharge.

Watchful Waiting for Prenatally Detected Ureteroceles

PURPOSE

Ureteroceles are commonly detected by prenatal ultrasound. Although many require surgical intervention due to obstruction of more than one renal moiety or obstruction of the bladder neck, some may be carefully observed. The objective of this study was to assess the outcome of conservative management in select cases of prenatally detected ureteroceles at a tertiary care pediatric hospital.

MATERIALS AND METHODS

We retrospectively reviewed the charts of patients with ureteroceles detected on prenatal ultrasound who were treated nonsurgically between 1990 and 2001.

RESULTS

A total of 10 cases were detected in the course of the chart review, with 6 involving duplex system and 4 involving single system ureteroceles. Median followup was 5 years (range 1 to 11). Patients were followed with routine ultrasound at 3 to 6-month intervals for the first 2 years, and at 6-month to 2-year intervals thereafter. Voiding cystourethrogram and renal scans or IVPs were performed initially in all patients. Those with vesicoureteral reflux were followed with annual or biennial cystogram until reflux resolution. Antibiotic prophylaxis was routinely prescribed for an average duration of 1.5 years. Initial ultrasound revealed unilateral hydronephrosis in all patients, with complete resolution in 6 during a mean followup of 2 years. Voiding cystourethrogram demonstrated vesicoureteral reflux of grade III or less in 4 patients. Reflux resolved in 2 of these patients during a mean followup of 3 years. No patient required surgical intervention within the time frame of this study.

CONCLUSIONS

There may be a role for watchful waiting in select cases of prenatally detected ureteroceles. Cases involving obstruction of more than one renal moiety, bladder neck obstruction or high grade vesicoureteral reflux were not selected among the population we followed, and would likely require initial surgical management. Patients without these complicating features may be safely followed on suppressive antibiotics, as based on our experience many of the associated problems may resolve without surgical intervention.

Simplified upper pole nephrectomy: initial experience

OBJECTIVE

To assess the results of an upper pole nephrectomy technique on 5 children.

MATERIALS AND METHODS

Upper pole nephrectomy was performed on 5 children, including 4 females and 1 male. Age ranged from 3 to 6 years old. The technique was performed without initial dissection of the renal pedicle. The upper pole is incised and removed. Upon its complete dissection, the segment that drains the upper pole is easily identified, clamped and sectioned.

RESULTS

Three children with ureterocele and 2 with ectopic ureter underwent this procedure. There was no intra- or postoperative complication with this technique. DSMA scintigraphy showed no decrease in renal function in the remaining kidney following the procedure.

CONCLUSION

The polar nephrectomy technique is simple, and has the advantage of not approaching the renal hilum, which makes surgery less laborious and prevents risk of renal damage, hemorrhage and decreased function in the remaining renal portion.

Urinary incontinence in a dog with an ectopic ureterocele

A 7-month-old, female English cocker spaniel was examined because of a complaint of urinary incontinence. Excretory urography revealed a small right kidney and right-sided hydroureter, ectopic ureter, and ureterocele. Ureteronephrectomy and ovariohysterectomy were performed, but the distal ureter and ureterocele were left in situ. Recurrent urinary tract infections and intermittent urinary incontinence persisted after surgery. Vaginourethrography demonstrated the presence of a urethral diverticulum associated with the ureterocele. Ureterocelectomy was performed, and the dog remains continent 4 years after ureterocelectomy. Persistent urinary incontinence and urinary tract infection were attributed to failure to resect the ureterocele.

Upper pole heminephrectomy: is complete ureterectomy necessary?

OBJECTIVE

To determine the re-operation rate on the distal ureter after upper pole heminephrectomy with incomplete ureterectomy.

PATIENTS AND METHODS

The case notes from one institution were reviewed retrospectively; 60 upper pole heminephrectomies with incomplete ureterectomy were undertaken in 39 girls and 16 boys (mean age at primary surgery 27 months, range 3--88).

RESULTS

Thirty-two children (58%) had an antenatal diagnosis while 12 (22%) presented with a urinary tract infection (UTI) and six (11%) with urinary incontinence. Twenty-nine of the 60 renal units (48%) had an associated ureterocele and in nine (15%) the ureter was ectopic. Ten infants (18%) underwent initial puncture of a ureterocele. Five patients (8%), all females, required lower urinary tract re-operation. The indications for secondary surgery were recurrent UTIs in all and a prolapsed ureterocele in one. All five had ultrasonographic evidence of a dilated ureteric stump. Reflux into the retained stump was detected in one child.

CONCLUSIONS

The re-operation rate for a redundant ureteric stump in this series was 8%. The risk of injury to the good ureter may outweigh the benefits of a complete ureterectomy.

Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele?

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.

Can a single individualized procedure predictably resolve all the problematic aspects of the pediatric ureterocele?

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.

Ureterocele prolapse-rare presentation in an adolescent girl

Ureterocele prolapse is a rare presentation of single system ureteroceles and is usually found early in childhood. We present a rare case of recurrent prolapse of a single system ureterocele that did not present until the patient was 17 years of age.

Long-term outcome based on the initial surgical approach to ureterocele

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.

Long-term outcome of transurethral puncture of ectopic ureteroceles: initial success and late problems

PURPOSE

We studied the long-term outcome of transurethral puncture of ectopic ureteroceles specifically associated with duplex systems.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent transurethral puncture of an ectopic ureterocele. Study exclusion criteria were orthotopic, bilateral and prolapsing ureteroceles.

RESULTS

We identified 19 girls and 2 boys, of whom 11 presented with prenatal hydronephrosis and 10 presented with urinary tract infection. Mean age at puncture was 5 months (range 0.5 to 60). Preoperatively voiding cystourethrography revealed no reflux in 7 patients, isolated ipsilateral lower pole reflux in 8, and bilateral and/or contralateral reflux in 6. Postoperatively studies initially showed no reflux in 8 cases but in 4 of the 8 reflux recurred up to 4 years after puncture. In 10 patients (48%) reflux developed into the ureterocele and upper pole segment. Repeat puncture was required 1 to 13 months after the initial procedure in 4 patients for persistent or recurrent upper pole hydroureteronephrosis. Subsequent open surgery was required in 15 of the 21 cases (71%), including ureterocele excision with ureteral reimplantation in 14. Of the children 10 and 4 underwent open surgery for recurrent urinary tract infection and progressive reflux, respectively, while 1 underwent ureteroureterostomy for progressive upper pole reflux. No patient underwent upper pole nephrectomy. Of the remaining 6 patients 4 have low grade reflux.

CONCLUSIONS

Transurethral puncture of ectopic ureteroceles provides effective short-term correction of upper pole obstruction but it is not definitive therapy in the majority of cases. Most children still require open surgery. In patients without reflux after the puncture procedure new onset, recurrent or progressive reflux may later develop with extended followup. Repeat puncture may be required to ensure adequate decompression in a minority of cases, as in the 20% in our series.

Long-term outcome based on the initial surgical approach to ureterocele

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.

Does the endoscopic incision of ureteroceles reduce the indications for partial nephrectomy?

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.

Applications of the KTP laser in the treatment of posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient

PURPOSE

We describes our experience using the potassium titanyl phosphate (KTP)-532 laser in treating posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient.

METHODS

A retrospective chart review was performed from 1987 to 1997 on a total of 33 pediatric patients who underwent retrograde endoscopic treatment for posterior urethral valves (PUV), ureteroceles (UC), and urethral strictures using a KTP-532 laser.

RESULTS

Overall, our success rate was excellent in the treatment of valves and ureteroceles. With a mean follow-up of three years in the PUV group, no urethral strictures of micturation abnormalities were seen. The majority of ureteroceles were decompressed and only half of our patients required and additional procedure. Our experience with urethral strictures, however, was not as promising. All of these patients ultimately required open urethral reconstruction.

CONCLUSION

The desirable thermal characteristics of the KTP laser, along with minimal complications and the availability of delicate pediatric endoscopic instruments have made this operation optimally suited for treating posterior urethral valves and ureteroceles in infants. However, the advantages for treating urethral strictures in children with the laser still remains to be established.

Ureteroceles in children: an ongoing challenge

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.

Transurethral puncture of ectopic ureteroceles in neonates and infants

Ten neonates and infants with 11 ectopic ureteroceles prospectively underwent transurethral puncture as the primary form of therapy. Of the 10 patients 6 had a prenatal diagnosis of uropathy and 4 presented postnatally with urinary tract infection. One patient had bilateral single system ectopic ureteroceles and 9 had a single ectopic ureterocele in a duplex system. Significant associated ipsilateral and/or contralateral urological pathology was noted in addition to the ectopic ureterocele in 7 patients. Transurethral puncture adequately decompressed 10 of the 11 ectopic ureteroceles (91%) and improved drainage of nonureterocele moieties in 3 cases. Iatrogenic reflux was found in 3 of the 11 ureterocele ureters. Urinary tract infection developed in 6 infants (4 with fever). Of the 10 patients 8 (80%) eventually required secondary surgical intervention because of recurrent urinary tract infections, persistent or iatrogenic reflux, or unresolving hydronephrosis. Although transurethral puncture rarely constitutes definitive treatment for ectopic ureterocele, there appears to be immediate benefit in cases of bilateral hydronephrosis or significant ipsilateral lower pole hydronephrosis. Decompression of the ureterocele is reliably obtained but it seldom obviates the need for more definitive reconstruction.

Experience with duplex system anomalies detected by prenatal ultrasonography

We reviewed 39 neonates with prenatally diagnosed duplex system anomalies. Principal diagnoses were ureterocele in 15 patients, ureteral ectopia in 15, lower polar vesicoureteral reflux in 6, lower pole ureteropelvic junction stasis in 2 and yo-yo reflux in an incompletely duplicated system in 1. Several patients had other ipsilateral and contralateral urinary anomalies. Ten patients (26%) had relevant physical signs and only 1 became symptomatic, with urosepsis, neonatally. At initial assessment, before any accounted urinary tract infection, renal polar function as judged by radionuclide examinations almost always was severely impaired in the presence of major ureteral ectopia or severe reflux. By contrast, function was usually well preserved when there was obstruction, or lesser degrees of ectopia or reflux. A total of 19 patients underwent surgery (14 electively and 5 after episodes of urosepsis), while 20 have been managed nonoperatively for 12 to 84 months (mean 34) during which time the appearances and function of the upper renal tracts have remained stable. We conclude that the natural history of these anomalies is often benign and that a policy of routine surgical intervention, developed when most cases presented symptomatically, may not be appropriate in patients who present antenatally.

Endoscopic incision of ureteroceles: intravesical versus ectopic

A total of 51 children, mostly less than 2 years old, underwent endoscopic incision of ureteroceles as a primary form of treatment. In 73% no further surgery was required. Of the patients 19 were diagnosed by prenatal ultrasound, with a urinary tract infection the usual presenting symptom in the remainder. Of 27 intravesical cases endoscopic incision resulted in decompression of the ureterocele in 93%, with preservation of upper pole function in 96%, and secondary surgical procedures were required in 7%. Reflux was created in 18% and it persisted in 2 of 4 patients. Of 24 cases of ectopic (extravesical) ureteroceles incision resulted in decompression in 75%, with upper pole function preserved in 50%. Reflux was created in 47% and a secondary surgical procedure was performed in 50%. Preservation of upper pole function was significantly better for intravesical versus ectopic ureteroceles (p < 0.01), and the requirement for secondary surgical procedure was greater with ectopic ureteroceles (p < 0.01). Three patients had intermittent bladder outlet obstruction following the incision and required further surgery. The 2 different techniques for incision of intravesical and ectopic ureteroceles are described. The role of endoscopic incision in the overall management of ureteroceles is confirmed by this review, and the need for partial nephroureterectomy may diminish.

Current management of duplex-system ureteroceles: experience with 41 patients

Experience is described of 41 infants and children with duplex-system ureteroceles, 25 presenting clinically and 16 by prenatal ultrasonography. Bladder outflow obstruction was rare but lower polar vesicoureteric reflux (VUR), usually of lesser grades, was common. Upper polar function, as assessed by 99mTc-DMSA, was negligible in children with truly ectopic ureteroceles but well preserved in those where the lesion lay wholly intravesically. Lower polar function was good, even in the presence of secondary obstruction, except in 2 infants with major VUR. Twenty-three patients were treated by upper polar nephrectomy plus aspiration of the ureterocele; 2 subsequently required ureterocele excision. Histology of excised specimens indicated that a more conservative approach would not have been rewarded. Where upper polar function was good, conservation was maintained in 3 cases by pyelopyelostomy and in 5 more by excision of the ureterocele plus bipolar ureteric reimplantation. Other operative strategies were employed in 2 cases. Finally, a defined group of 8 children was managed expectantly without untoward results. It was concluded that the variable anatomy and function associated with duplex-system ureteroceles require a flexibile approach to treatment, including, possibly, no treatment at all.

A 20-year experience with treatment of ectopic ureteroceles

Between 1970 and 1990 a total of 37 patients (female-to-male ratio 3.6:1) was diagnosed and treated at our institution for ectopic ureterocele. Urinary tract infection was the most frequent mode of presentation (59%). Of the patients 54% were less than 3 years old at operation. Transurethral incision of ectopic ureterocele served only as a decompressive procedure for acutely ill infants and was followed with a high incidence (80%) of resultant vesicoureteral reflux. The elective surgical policy was individualized based on renal function and presence of vesicoureteral reflux. Overall results within the various groups were generally satisfactory regarding eradication of urinary tract infections, preservation of renal function and continence or treatment of vesicoureteral reflux. Upper pole heminephrectomy and partial ureterectomy were performed in 14 patients with 3 (21%) requiring reoperation, including only 2 (14%) subsequent reimplantations. Thus, we believe that an expectant approach to the lower urinary tract is well recommended in the majority of the patients with a poorly functioning ipsilateral renal segment. A modified technique of total reconstruction, performing only partial ureterectomy with double barrel reimplantation, was successful in 7 patients.