Current role of simplified upper tract approach in the surgical treatment of ectopic ureteroceles: a single centre's experience.

Abstract

Despite renewed interest in either endoscopic decompression or complete reconstruction as primary approaches in ectopic ureterocele's (EU's) treatment, we advocate that a simplified upper tract approach is an optimal choice in a large subset of these patients. We review our surgical results to evaluate the effectiveness of different surgical procedures used in the treatment of EU, based on an individualized approach. We retrospectively analysed all patients with EU and without previous treatment (n = 59) operated in this centre between the years 1991 and 2000. This disorder was bilateral in three patients (62 EU) and associated with duplex ureters in 60 cases. Vesicoureteral reflux (VUR) was diagnosed pre-operatively in 49.1% of patients. Treatment and choice of procedure was based on patients' age, clinical manifestations, associated abnormalities and function of the ureterocele-bearing moiety. Patients were divided in three separate groups according to the initial surgical approach. Group 1-11 patients submitted to endoscopic puncture (six urgent ureterocele decompression, four infants with obstruction of a functional ureterocele-bearing moiety and another with both lower pole ureter and mild bladder outflow obstruction). Group 2-30 patients (31 EU) submitted to a simplified upper tract approach--pyeloureterostomy (1), heminephrectomy (29) and nephrectomy (1) (all patients but one with non-viable renal segments; VUR, grade < or = III, present in six cases). Group 3-18 patients (20 EU) submitted to complete primary reconstruction (all patients with high-grade and/or contralateral reflux, with or without function of the ureterocele-bearing moiety). Success (clinically asymptomatic patients, without obstruction or VUR) and complication rates from the different approaches were analysed. For statistical evaluation, we used Fisher's exact test with p < or = 0.05 considered significant. The success rate of endoscopic treatment, simplified upper tract approach and complete reconstruction were 18.2%, 80% and 83.3%, respectively. Major complications occurred in two patients from group 3. Endoscopic puncture is our first option when immediate ureterocele decompression is required, although it seldom affords definitive treatment. Complete primary reconstruction is necessary in complex cases. Cure rates are high but there is a potential risk for serious complications. A simplified upper tract approach is curative in most patients without associated reflux. Heminephrectomy remains our first choice in a large subset of patients with non-viable or hypofunctional renal segments and without high-grade reflux.