Concomitant Vesicoureteral Reflux Research Articles

Significant improvement in hydronephrosis with pyeloplasty prior to 3 months of age in patients with antenatal severe hydronephrosis.

Pyeloplasty is the definitive management of ureteropelvic junction obstruction (UPJO). One of the challenging questions is when to perform pyeloplasty. We studied if improvement post-pyeloplasty in the first 3 months of life could show greater improvement in hydronephrosis than surgery at an older age. Patients with postnatally diagnosed UPJO and underwent pyeloplasty in the first year of life were retrospectively reviewed. We excluded patients with concomitant vesicoureteral reflux, and patients who had pyeloplasty because of UTI or missed follow-up. Patients were divided into two groups, according to the age at pyeloplasty, before and after the age of 3 months. We collected patients' demographics, anteroposterior diameter of the renal pelvis (APD), SFU grade, renogram data, perioperative data (surgery duration, hospital stay, and ureteral stent duration) and postoperative ultrasound changes. The percentage of change of APD (Δ%APD) was calculatedusing the formula: Δ%APD = [ (initial APD-last APD)/initial APD] *100. We included 90 patients (93 renal units). 36 patients had pyeloplasty during the first 3 months of life and 57 patients at 3 -12 months. Patients' characteristics were similar in both groups except APD which was higher when pyeloplasty was done < 3 months of age (p = 0.02). Both groups had comparable perioperative parameters. After almost similar follow-up period of both groups. The Δ%APD was 58% when pyeloplasty was done < 3 months compared to 33% when was performed > 3 months (p = 0.009). Using Kaplan-Meier analysis, APD significantly improved when pyeloplasty was performed before the age of 3 months (p = 0.001). Early pyeloplasty, in the first 3 months of life, showed a significant improvement of APD postoperatively than those had surgery later. It is unclear if this will relate to less loss of renal function yet certainly this would be suspected and feel this finding provides some evidence for early intervention.

Voiding Cystourethrogram Before Pyeloplasty: To Do or Not To Do?

To assess the incidence of concomitant vesicoureteral reflux (VUR) in unilateral cases of ureteropelvic junction obstruction(UPJO) and to identify factors that predict VUR. Files of 381 pediatric patients who underwent unilateral pyeloplasty between 2000 and 2017 were retrospectively reviewed.A total of 270 patients with available data and ≥5 years of follow-up were eligible for this study.Demographic parameters,preoperative hydronephrosis grade,renal pelvis anteroposterior diameter(APD),renal parenchymal thickness(PT),split renal functions on MAG-3 scan and VUR status were noted.The patients were divided into two groups:Those with concomitant VUR(Group I, n:24, 8.9%) and those without VUR(Group II,n:246, 91.1%). Among 270 patients(205 boys,75.9%) with a median age of 4 months(2-98),197 (72.9%)had antenatal hydronephrosis.Median follow-up was 11 years(5-22).Among 24 patients with concurrent VUR,6(25%) had Grade II VUR,whereas Grade III-V VUR was detected in 18(75%).Of these,12(50%) had ipsilateral VUR,3(12.5%) had contralateral,and 9(37.5%) had bilateral VUR.In a median 137-month follow-up,spontaneous VUR resolution was observed in 6(25%) patients,whereas 15 (62.5%) patients underwent endoscopic subureteral injection and 3(12.5%) patients ureteroneocystostomy,respectively.Preoperative APD[35.5, IQR(27.6-36.0) vs. 26.5 IQR(25.0-35.0), p=0.004] were significantly higher in Group I,whereas Group I had significantly lower PT[3.7, IQR(3.4-6.4) vs. 5.8 IQR(4.4-6.1), p=0.026].Predictive factors for concomitant VUR were presentation with febrile UTI(OR:2.769,p=0.048), PT<3.95 mm(OR:1.367,p=0.043),and APD>28.8 mm (OR:1.035,p=0.001). Our results indicated that concomitant VUR and UPJO might be detected in 1 out of every 11 patients undergoing pyeloplasty,while some type of surgical intervention for VUR was required in 75% of these patients.Thus,VCUG prior to pyeloplasty may be limited in those presenting with febrile UTI,having higher APD and lower PT on preoperative urinary ultrasonography.

Does preoperative screening VCUG affect the outcomes and complications of pyeloplasty in patients with ureteropelvic junction obstruction?

The role of voiding cystourethrogram (VCUG) in evaluating vesicoureteral reflux (VUR) in patients with known ureteropelvic junction obstruction (UPJO) remains unclear. While VCUG is frequently performed, the incidence of concomitant VUR and UPJO is low, and VUR is often low-grade with high rates of spontaneous regression. To analyze the clinical relevance of VCUG in patients with UPJO by determining its incidence and studying the difference in clinical outcomes between patients with known, unknown, and negative VUR. Retrospective review of patients with UPJO who underwent pyeloplasty from 2012 to 2020 with <18 years-old, unilateral UPJO, postoperative follow-up of ≥2 months and had at least 1 renal ultrasound (US) after pyeloplasty. Results were compared among 3 groups: patients who underwent VCUG before pyeloplasty and were found to have VUR (group 1), patients who underwent VCUG before pyeloplasty without VUR (group 2), and patients who did not have a VCUG before pyeloplasty (group 3). A total of 275 patients met the inclusion criteria, of which 21 patients were classified in group 1, 166 patients in group 2, and 88 patients in group 3 (Table). The age at preoperative VCUG was 14.7±32.9 months in group 1 and 15.17±35.8 months in group 2 (p=0.960). Overall, the incidence of concomitant UPJO and VUR was 11.2%. In group 1 the initial VUR grade was 5 in 2 patients, 4 in 3, 3 in 5, 2 in 7, and 1 in 4 patients. Of these, only 1 patient required ureteral reimplantation after pyeloplasty. Post-pyeloplasty, no significant differences were observed in complications (p=0.7436), length of follow up (p=0.3212), SFU grade 4 hydronephrosis (p=0.2247), postoperative UTIs (p=0.1047) and pyeloplasty success rate (p=0.4206) among the 3 groups. Despite the use of antibiotic prophylaxis being significantly different amongst the three groups (p<0.001), it was not associated with a lower incidence of postoperative UTIs (group 1 p=0.068, group 2 p=0.486, group 3 p=1). In patients with reflux, an increase in age was associated with a decrease in the rates of complications (p=0.019). We found no significant difference in the outcomes in patients who had a preoperative VCUG as compared to those who did not. The preoperative diagnosis of VUR by VCUG changed the management in less than 1% of the study population and thus its role in patients with UPJO should be reevaluated.

A novel endoscopic approach for management of hutch diverticulum concomitant vesicoureteral reflux with dextranomer/hyaluronic acid copolymer injection

There are various treatment options for symptomatic bladder diverticulum, including robotic-assisted laparoscopic bladder diverticulectomy, open and endoscopic techniques. But, to date, the optimal surgical technique remains unclear. To present the preliminary long-term follow-up results of a novel technique of dextranomer/hyaluronic acid copolymer (Deflux) plus autologous blood injection for correction of hutch diverticulum in patients with concomitant vesicoureteral reflux (VUR). We retrospectively reviewed four patients who had hutch diverticulum with concomitant VUR and had undergone submucosal Deflux following autologous blood injection. Patients with neurogenic bladder, posterior urethral valve, or voiding dysfunction were excluded from the study. Success was defined as the resolution of the diverticulum, hydronephrosis, and hydroureter on ultrasonography at a 3-month follow-up and long-term symptom-free period. Four patients with hutch diverticula were included. The median age at the time of surgery was 6.1 (range 3-8) years. Three of them had unilateral VUR, and one had bilateral VUR. During the procedure, a mean of 0.625ml Deflux plus a mean of 1.25ml autologous blood were injected submucosally for correction of VUR. Additionally, a mean of 1.62ml Deflux plus a mean of 1.75ml autologous blood were injected submucosally to occlude the diverticulum. The median follow-up was 4.6 (range 4-8) years. This method had excellent success in all patients in the current study with no postoperative complications such as febrile urinary tract infection, or diverticulum, hydroureter, or hydronephrosis in follow-up ultrasounds. Submucosal injection of Deflux plus autologous blood injection can be a successful endoscopic intervention for treatments of hutch diverticulum in patients with concomitant VUR. Deflux injection can be a simple and cost-effective technique.

Concurrence of Vesicoureteral Reflux and Gastroesophageal Reflux Disease in Children

Background: There is anecdotal evidence regarding the simultaneous occurrence of vesicoureteral reflux (VUR) and gastroesophageal reflux disease (GERD), which indicates the probability of pathophysiological commonality. Objectives: In the present study, we evaluated the concurrence of VUR and GERD in children candidates for the voiding cystourethrogram (VCUG) study. Methods: This cross-sectional study was conducted on 62 children between 1 and 14 years old referred to a tertiary referral teaching hospital for VCUG in 2019 - 2020. All subjects underwent ultrasound to assess GERD and VCUG to rule out VUR. Results: According to the ultrasound assessment, 14.5% of subjects were diagnosed with GERD: 8.3% in males and 18.4% in females. VUR was detected in 48.4% of children (50.0% in males and 47.4% in females) using VCUG. Overall, seven (23.3%) had concomitant VUR and GERD: 4.2% in boys and 15.8% in girls, indicating no difference between the two genders (P = 0.125). The prevalence of concurrent GERD and VUR was also independent of age. In the two groups with and without VUR, the prevalence of GERD was 23.3% and 6.2%, respectively, indicating a relative risk of 2 (95% confidence interval [CI]: 1.32 - 3.02, P = 0.001). Conclusions: Regarding the relationship between GERD and VUR, despite the deletion of physiologic GER cases, the pathophysiological overlap between the two phenomena could be considered.

Ectopic Ureter: Surgical Management

The ectopic ureter is an uncommon presentation in the pediatric population, seen in approximately one in 2,000 live births with a female prevalence. However, observation and conservative management have a short-lived role as many of these children are incontinent or symptomatic from an obstructed system. Urgent decompression of an infected system may be required as a temporizing measure before definitive surgical management can be pursued. In this review, we discuss the surgical options available for the ectopic ureter. This includes heminephrectomy of the nonfunctioning renal unit and reconstructive measures such as ureteral reimplantation, ureteroureterostomy, and ureteropyelostomy. We also discuss the management of the remnant ureteral stump and concomitant vesicoureteral reflux. This review contains 1 figure and 35 references. Key words: cutaneous ureterostomy, ectopic ureter, renal duplication anomalies, heminephrectomy, ureteral reimplantation, ureteropyelostomy, ureteroureterostomy

Should micturating cystourethrogram be routinely performed for paediatric pyeloplasty patients?

Objective: Micturating cystourethrogram (MCUG) has traditionally been recommended as part of the preoperative evaluation of all cases of hydronephrosis. Several studies have shown that the majority of cases with pelviureteric junction obstruction (PUJO) and concomitant vesicoureteral reflux (VUR) were of low-grade and generally resolved spontaneously. We therefore retrospectively evaluated the need for routine MCUG in all cases of PUJO. Methods: We conducted a retrospective review of clinical records of all patients who underwent pyeloplasty in our institution between 2003 and 2015. Data collected included patient demographics, clinical presentation, radiological procedures performed, operative details as well as postoperative outcomes. Results: A total of 119 patients underwent pyeloplasty for PUJO during this study period. MCUG was performed in 88 patients (74%), of whom eight patients had VUR. All eight patients had unilateral PUJO and two patients had bilateral VUR. Only two patients had high-grade VUR (grade 4). These two patients also had hydroureter detected on ultrasound scan (US). All patients with VUR had spontaneous resolution of reflux. While comparing outcomes for patients with and without VUR, there was no statistically significant difference in terms of the need for redo surgery and improvement in differential renal function post-pyeloplasty. Conclusion: The outcome of pyeloplasty appears to be independent of the presence of concomitant VUR. Therefore, we conclude that MCUG does not need to be performed routinely for all PUJO patients. However, patients with history of recurrent urinary tract infection or findings of hydroureter on US should still be investigated with MCUG.

Endoscopic correction of vesicoureteral reflux in children with solitary functioning kidney: insertion of a double-J stent to avoid transient ureteral obstruction.

Children with solitary functioning kidney, especially those with concomitant vesicoureteral reflux, are at increased long-term risk of kidney damage. Acute obstruction is a rare but relevant concern after endoscopic correction of vesicoureteral reflux and might be more symptomatic in children with solitary functioning kidney. We hereby report our experience and routine practice in using ureteral stents for prevention of the potential acute obstruction after endoscopic correction of reflux in children with solitary functioning kidney. A retrospective chart review was performed to find children with solitary functioning kidney that were endoscopically treated for vesicoureteral reflux. Solitary functioning kidney was defined as congenital or acquired (contralateral renal function <10 % in dimercaptosuccinic acid scan). Data regarding age, sex, grade and side of vesicoureteral reflux, and follow-up information were gathered. A tethered double-J stent was inserted after endoscopic bulking agent injection in all patients. Stents were removed using the extraction string at 2 weeks postoperatively. Between 2008 and 2015, a total of 28 patients (16 females) with solitary functioning kidney were treated endoscopically and underwent concomitant double-J insertion. Reflux was grade II in 12 (42.9 %), grade III in 10 (35.7 %), and grade IV in 6 (21.4 %) patients before treatment. No complication was encountered postoperatively or at removal of the stents using extraction strings. Considering devastating sequelae of acute obstruction following endoscopic management of reflux in children with solitary functioning kidney, routine use of double-J stents might be a feasible and safe approach.

The Management of Vesicoureteral Reflux in the Setting of Posterior Urethral Valve With Emphasis on Bladder Function and Renal Outcome: A Single Center Cohort Study

To represent our experience in the management of posterior urethral valves and concomitant vesicoureteral reflux (VUR). A total of 326 children with posterior urethral valve who had underwent valve ablation/bladder neck incision were studied, and those who had persistent VUR and were categorized under 3 main groups were followed up. Group 1 (n= 71) received prophylactic antibiotic, group 2 (n= 50) underwent Deflux injection (2a) (n= 28): Deflux injection alone, group 2b (n= 22) Deflux with concomitant autologous blood injection (HABIT), and group 3 (n= 19) underwent ureteroneocystostomy before referral and was followed up conservatively. VUR resolution, incidence of urinary tract infections (UTI), and bladder function were assessed. Mean duration of follow-up was 3.8years; VUR resolution occurred in 66.1%, 86.0%, and 94.0% of groups 1-3, respectively (P= .013). Resolution rate in group 2b was significantly higher than group 2a (90.9% vs 78.5%). Patients in group 2 experienced a longer UTI-free period compared with others (P<.05). Urodynamic studies demonstrated significant decrease in maximum voiding detrusor pressure and detrusor overactivity in all groups (P<.001). Children in group 3 ended up with lower compliance compared with others (P<.001). After toilet training, only 2.8%, 21.4%, 13.6%, and 27% children were diagnosed with lower urinary tract dysfunction in groups 1-3, respectively (P= .027). Myogenic failure developed only in 3 boys in group3. Ablation/bladder neck incision leads to significant improvement in VUR status in part because of improvement in bladder function. After successful valve removal, conservative therapy can be regarded as the mainstay of reflux treatment, whereas HABIT is recommended for high grade VUR associated with febrile UTI or deterioration in renal function.

The Outcome of Initial Endoscopic Treatment in the Management of Concomitant Vesicoureteral Reflux and Ureteropelvic Junction Obstruction

To report the results of a single-center experience with the endoscopic injection of Deflux as the initial minimally invasive approach in patients with vesicoureteral reflux (VUR) and coexisting obstruction at the ureteropelvic junction (UPJO) level who presented with VUR. Between May 2004 and July 2011, 2810 children with a diagnosis of VUR were referred to our center; 143 (5%) had concomitant UPJO. On the basis of the study inclusion criteria, 76 were included. All patients received antibiotic therapy. VUR and UPJO resolved in 50 children without the need for further intervention, and 26 underwent endoscopic Deflux injection by applying the hydrodistention autologous blood injection technique (HABIT). All patients received antibiotic prophylaxis until resolution of VUR was confirmed on voiding cystourethrogram (VCUG). Patients underwent follow-up visits at 1, 6, and 12 months postoperatively. At a mean follow up of 20.0 ± 1.6 months, 20 of those with concomitancy showed resolution of VUR and the coexisting UPJO after the first injection (success rate, 76.9%), and 2 resolved after the second injection, leading to an overall success rate of 84.6%. Finally, 3 patients required further ureteral reimplantation, and 3 underwent pyeloplasty for correction of UPJO by applying miniature pyeloplasty technique. Differential renal function was preserved in all patients. Performing an initial endoscopic injection of Deflux in the management of concomitant VUR and UPJO provides promising results in terms of spontaneous resolution of obstruction at the UPJ level and complete resolution or decrease in hydronephrosis.

Editorial Comment

Concurrent vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) represent a potential diagnostic and therapeutic dilemma because it can sometimes be difficult to determine if the UPJO is primary or secondary to VUR. In some series, a pyeloplasty rate of 75% has been reported in children who present with simultaneous VUR and UPJO. 1 Bomalaski M.D. Hirschl R.B. Bloom D.A. Vesicoureteral reflux and ureteropelvic junction obstruction: association, treatment options and outcome. J Urol. 1997; 157: 969-974 Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The management algorithm used in the treatment of patients with simultaneous VUR and UPJO therefore carries with it significant therapeutic and costs implications, especially in this era of robotic-assisted ureteropelvic junction repair. If we can reduce the need for ureteropelvic junction repair in this population, we can reduce the morbidity and costs. The Outcome of Initial Endoscopic Treatment in the Management of Concomitant Vesicoureteral Reflux and Ureteropelvic Junction ObstructionUrologyVol. 81Issue 5PreviewTo report the results of a single-center experience with the endoscopic injection of Deflux as the initial minimally invasive approach in patients with vesicoureteral reflux (VUR) and coexisting obstruction at the ureteropelvic junction (UPJO) level who presented with VUR. Full-Text PDF ReplyUrologyVol. 81Issue 5PreviewThe traditional management of children with vesicoureteral reflux (VUR) and ureteropelvic junction obstruction (UPJO) is pyeloplasty as the initial step, and if the high-grade reflux remains symptomatic after pyeloplasty, surgical correction of the reflux is the next step.1 It was postulated that the nearby obstruction to the renal parenchyma might cause more renal damage, so it should be managed sooner rather than later. Moreover, in a few pediatric urology centers, this concept has ultimately been changed by surgical correction of reflux (ureteral reimplantation) initially, followed by pyeloplasty in persistent UPJO. Full-Text PDF

Outcomes of Targeted Treatment for Vesicoureteral Reflux in Children with Nonneurogenic Lower Urinary Tract Dysfunction

There is a known association between nonneurogenic lower urinary tract conditions and vesicoureteral reflux. Whether reflux is secondary to the lower urinary tract condition or coincidental is controversial. We determined the rate of reflux resolution in patients with lower urinary tract dysfunction using targeted treatment for the underlying condition. Patients diagnosed and treated for a lower urinary tract condition who had concomitant vesicoureteral reflux at or near the time of diagnosis were included. Patients underwent targeted treatment and antibiotic prophylaxis, and reflux was monitored with voiding cystourethrography or videourodynamics. Vesicoureteral reflux was identified in 58 ureters in 36 females and 5 males with a mean age of 6.2 years. After a mean of 3.1 years of treatment reflux resolved with targeted treatment in 26 of 58 ureters (45%). All of these patients had a history of urinary tract infections before starting targeted treatment. Resolution rates of vesicoureteral reflux were similar for all reflux grades. Resolution or significant improvement of reflux was greater in the ureters of patients with dysfunctional voiding (70%) compared to those with idiopathic detrusor overactivity disorder (38%) or detrusor underutilization (40%). Vesicoureteral reflux associated with lower urinary tract conditions resolved with targeted treatment and antibiotic prophylaxis in 45% of ureters. Unlike the resolution rates reported in patients with reflux without a coexisting lower urinary tract condition, we found that there were no differences in resolution rates among grades I to V reflux in patients with lower urinary tract conditions. Patients with dysfunctional voiding had the most improvement and greatest resolution of reflux. Additionally grade V reflux resolved in some patients.

Children and adolescents with ureteropelvic junction obstruction: is an additional voiding cystourethrogram necessary? Results of a multicenter study

The incidence of ureteropelvic junction obstruction (UPJO) and concomitant vesicoureteral reflux (VUR) ranges from 14 to 18 %. Therefore, different guidelines recommend a voiding cystourethrogram (VCUG) to identify cases of VUR early in the diagnostic process. Aim of this multicenter study was to reassess the incidence of concomitant VUR and the need for additional VCUG in a large cohort of patients with UPJO. Furthermore, we asked for clinical objectives that defined the need for VCUG with the intention of minimizing radiation exposure and the need for invasive diagnostic procedures. Medical records for 266 patients (69 girls, 197 boys) with UPJO were analyzed retrospectively. Data were obtained on gender, clinical symptoms, results of pre- and postnatal ultrasound, VCUG and 99(m)Technetium-MAG3 (MAG3) scan. They were correlated with the incidence of concomitant VUR. One hundred and seventy-eight patients (67 %) underwent VCUG. Concomitant VUR was detected in 13 patients. Dilating VUR (dVUR) was observed in 11 patients. In our study, the overall incidence of a concomitant VUR was 7.3 %. In cases of proven VUR, we observed a positive predictive value for female gender, ureteral dilatation, renal insufficiency, and recurrent urinary tract infections (UTI). But there was no correlation between concomitant VUR and the severity of hydronephrosis. Our data suggest that the low incidence of concomitant VUR in cases of UPJO does not justify the routine use of VCUG as a routine diagnostic tool. Especially, ureteral dilatation and recurrent UTI have a positive predictive value for concomitant VUR.

Caliceal Diverticula in Children: Natural History and Management

The natural history of caliceal diverticula in children is unknown. We review our series of children with caliceal diverticula to examine the presentation, natural history and management. We retrospectively reviewed the records of 22 children presenting with caliceal diverticula between 1983 and 2006. All pertinent clinical data were recorded, including demographics, imaging studies, treatment and clinical outcome. A total of 22 children had 23 caliceal diverticula. There were 14 girls and 8 boys who presented at a mean age of 5.4 +/- 3.1 years (range 0.2 to 12). At clinical presentation 10 patients had febrile urinary tract infection, 2 had hematuria, 2 had abdominal pain, 1 had flank pain and 8 were asymptomatic. Mean diameter of all caliceal diverticula was 2.2 +/- 1.7 cm. All patients underwent voiding cystourethrogram. Two patients (9%) had concomitant ipsilateral caliceal diverticula and vesicoureteral reflux. A total of 10 patients with caliceal diverticula (43%) were treated at a mean of 3.0 +/- 2.3 years after initial presentation due to symptomatic enlargement in 5, symptomatic calculus in 3, complicated abscess in 1 and urosepsis in 1. Treatment modalities included percutaneous ablation, open marsupialization/ablation, partial nephrectomy and laparoscopic marsupialization/ablation. There were no recurrences during a mean followup of 3.1 +/- 2.9 years (range 0.1 to 10.1) in these 10 patients. In the 13 caliceal diverticula (57%) that were observed mean followup was 6 +/- 3.7 years (range 1.2 to 10.5). These caliceal diverticula were stable in size and remained asymptomatic. Caliceal diverticula in children are rare. Most caliceal diverticula remain stable and asymptomatic but approximately 20% may have symptomatic enlargement that may warrant surgical management. Given the morbidity associated with caliceal diverticula and concomitant vesicoureteral reflux, evaluation for ipsilateral reflux is mandatory. Overall approximately 43% of children with caliceal diverticula require surgical intervention, and various treatment options are available.

Vesicoureteral Reflux and Duplex Systems

Vesicoureteral reflux (VUR) is the most common anomaly associated with duplex systems. In addition to an uncomplicated duplex system, reflux can also be secondary in the presence of an ectopic ureterocele with duplex systems. Controversy exists in regard to the initial and most definitive management of these anomalies when they coexist. This paper will highlight what is currently known about duplex systems and VUR, and will attempt to provide evidence supporting the various surgical approaches to an ectopic ureterocele and duplex system and the implications of concomitant VUR.

Evolution of Endoscopic Management of Ectopic Ureterocele: A New Approach

We report the evolution of endoscopic treatment of ectopic ureteroceles from the unroofing technique to a novel approach using concomitant ureterocele double puncture and intraureterocele fulguration. We also compare the results of different endoscopic modalities at a single center. We reviewed the records of 46 children with ectopic ureteroceles who were treated endoscopically between 1995 and 2005. The patients were divided into 2 main groups. Group 1 included 17 patients who underwent common endoscopic treatments, including ureterocele incision (4 patients), single ureterocele puncture (4), and single puncture with insertion of a Double-J stent (9). Group 2 included 29 children who underwent ureterocele double puncture and fulguration of the anterior and posterior walls of the collapsed ureterocele after insertion of a Double-J stent into both punctured sites. We also managed concomitant vesicoureteral reflux by endoscopic injection of tricalcium phosphate ceramic into the subureteral region. Total success rates in group 1 were 0%, 25% and 33% in patients who underwent ureterocele incision, single ureterocele puncture and single puncture with insertion of a stent, respectively. Total success rate in group 2 was 90% (p<0.05). New onset vesicoureteral reflux developed in 8 patients (47%) in group 1, of which 6 were in ureterocele moieties, and in 8 patients (28%) in group 2, with none in a ureterocele moiety (p<0.01). A total of 13 patients (76%) in group 1 required open surgical intervention, compared to 3 (10%) in group 2 (p<0.05). This new endoscopic approach is highly effective in the treatment of children with ectopic ureteroceles.

Vesicoureteral Reflux and Ureteropelvic Junction Obstruction: Association, Treatment Options and Outcome

We investigated the association, treatment options and outcomes of patients with ureteropelvic junction obstruction and concomitant vesicoureteral reflux. We analyzed 6,790 consecutive pediatric urology records at our university. Treatment options included observation, and primary pyeloplasty, ureteroneocystostomy and nephroureterectomy. Hydronephrosis, reflux and obstruction were judged as resolved, improved, unchanged or worse. A total of 1,140 patients had vesicoureteral reflux, 224 had ureteropelvic junction obstruction and 41 had both conditions (39 ipsilateral and 6 contralateral kidneys). There was no increased risk of obstruction in patients with reflux when all grades of reflux were grouped (odds ratio 1.26, confidence interval 0.91 to 1.71). In contrast, subgroup analysis of patients with high grade reflux demonstrated a 5-fold increased risk of obstruction (odds ratio 5.0, confidence interval 2.4 to 10.8). One patient was lost to followup. Observation of 6 kidneys led to resolution of reflux in 3 (50%), resolution of obstruction in 3 (50%) and resolution or improvement of hydronephrosis in 4 (67%). Primary pyeloplasty was done on 29 kidneys with 10 (35%) requiring subsequent ureteroneocystostomy. At latest followup hydronephrosis resolved or improved in 24 patients (83%), vesicoureteral reflux resolved or improved in 19 (66%) and ureteropelvic junction obstruction resolved in all. Primary ureteroneocystostomy was performed on 5 kidneys, all of which required subsequent pyeloplasty. Hydronephrosis resolved in 3 patients (60%), and reflux and obstruction resolved in all. Two patients treated with primary nephroureterectomy, and 1 who underwent concomitant pyeloplasty and ureteroneocystostomy have had no subsequent urological problems. One patient awaits primary pyeloplasty. High grade vesicoureteral reflux is associated with ureteropelvic junction obstruction. No association with low or intermediate grade reflux was demonstrated. While some patients may be monitored expectantly, in our series pyeloplasty or nephrectomy was required in 81% and ureteroneocystostomy was required in 36%. In no case did primary ureteroneocystostomy protect against the subsequent need for pyeloplasty.