Treatment Of Primary Obstructive Megaureter Research Articles

Comparative study of cystoscopic control vs. radiological control in the endoscopic treatment of primary obstructive megaurater.

High-pressure balloon pneumatic dilatation for the treatment of primary obstructive megaureter (POM) was initially described under cystoscopic and radiological control. However, some groups use cystoscopic control only, in an attempt to avoid the ionizing radiation associated with the procedure. A retrospective study of POM patients treated with pneumatic dilatation in our unit from 2008 to 2021 was carried out. Success rates, complications, and follow-up were compared between two groups -dilatation under cystoscopic control alone (CS) vs. dilatation under radiological control only (RX). 23 patients -9 CS and 14 RX- underwent surgery. Both groups were demographically comparable. Mean hospital stay was significantly shorter in the CS group (1 vs. 2 days; p = 0.009). Operating time was longer in the RX group (78 vs. 30 min; p = 0.001). Ureterovesical junction (UVJ) dilatation was successful in 100% of CS vs. 79% of RX cases; RR: 3.87 (0.51-26.99). Postoperative complications were similar in both groups; RR: 3.87 (0.51-26.99). Double J stent migration occurred in one case in both groups; RR: 0.64 (0.05-9.03). In the long-term, treatment success rate was higher in the CS group (100% vs. 71%); RR: 3.87 (0.51-26.99). POM pneumatic dilatation under cystoscopic control alone is faster, without increasing the risk of complications. Based on our experience, we suggest ionizing radiation be removed, since we consider it to be unnecessary.

Results of primary obstructive megaureter treatment using high-pressure balloon dilatation of ureterovesical junction in children

Aim. To evaluate the age dependence of efficacy and safety in high-pressure balloon dilatation (HPBD) for primary obstructive megaureter (POM) in children under 2 years.
 Materials and methods. From 2020 to 2022, we performed a single-center, unblinded study, with a total of 200 children, treated with HPBD for POM: 117 boys and 83 girls. Study included patients from 1 month to 2 years. The follow-up period was 1 year.
 Results. In this series the overall treatment effectiveness was 92.5%. In 15 cases treatment was not effective and these children proceeded with ureteral reimplantation. We didn’t achieve positive treatment results in children older than 15 months and our statistical model was not significant for failed cases. Treatment failure we presumed to be due to hard to dilate severe stenosis and extreme length of the stenotic area.
 Conclusion. In our study we found HPBD of uretero-vesical junction to be safe and effective method for treatment of primary obstructive megaureter in young children. The overall success rate was 92.5%. We recommend considering HPBD as the first line treatment for POM in young children. In failure cases we suggest to perform ureteral reimplantation.

Single-port-plus-one robot-assisted laparoscopic modified Lich-Gregoir direct nipple ureteral extravesical reimplantation in children with a primary obstructive megaureter.

To introduce a new technique of single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation and ascertain its validity in the treatment of pediatric primary obstructive megaureter. Between January 2021 and November 2021, we retrospectively analyzed the clinical data of 12 children with primary obstructive megaureter who were admitted to the Department of Pediatric Surgery of Fujian Provincial Hospital. All 12 children were treated with single-port-plus-one robotic laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation. Five of them were female and seven were male, including nine cases were simple obstructive type, while the remaining three cases were obstructive with reflux type. The mean age of the children was 17.33 ± 6.99 (10-36) months and the mean follow-up time was 14.16 ± 1.75 (12-17) months. Changes in preoperative and first-year postoperative parameters were compared. The mean operative time for all 12 children was 123.58 ± 10.85 (110-145) min, with a mean internal operative time of 101.42 ± 0.85 (90-120) min, a mean operative bleeding time of 2.42 ± 0.67 (2-4) ml, and a mean hematuria duration of 16.08 ± 1.44 (14-19) h. The mean indwelling catheterization time was 2.25 ± 0.45 (2-3) days and the mean hospitalization time was 3.83 ± 0.39 (3-4) days. At the postoperative first year, the ureteral diameter, calyceal diameter, and anterior-posterior renal pelvic diameter were found to be significantly smaller than at the preoperative period (18.83 ± 3.21 mm vs. 6.83 ± 1.27 mm, 13.99 ± 3.58 mm vs. 3.5 ± 2.90 mm, and 34.92 ± 4.25 mm vs. 10.08 ± 1.88 mm, P < 0.001). There was a significant increase in renal cortical thickness and the percentage of differential renal function (3.63 ± 1.66 mm vs. 5.67 ± 1.88 mm, 33.75 ± 2.77 mm vs. 37.50 ± 1.31 mm, P < 0.001). The resolution rate of obstruction was 100% and no child developed DeNovo vesicoureteral reflux. The technique of modified Lich-Gregoir direct nipple ureteral extravesical reimplantation can help maintain the physiological direction of the ureter and at the same time enhance the effectiveness of antirefluxing in robotic surgery. The design of a single-port-plus-one wound can produce a cosmetic appearance by concentrating and hiding the wound around the umbilicus. This modified reimplantation procedure has the potential to become a promising technique in the robot-assisted treatment of primary obstructive megaureter.

Comparison of Treatment Methods of Primary Obstructive Megaureter

BACKGROUND: Primary megaureter (PM) is a common congenital uropathy. In this study, we compared the results of treatment options for primary megaureter with obstruction in UVJ.&#x0D; METHODS: The files of all patients who underwent open surgery and had a double J (JJ) ureteral stent for treating primary obstructive megaureter in our institution between 2010 and 2023 were evaluated retrospectively. The demographic information of the patients, the results of imaging tests before and after the surgery, early and late complications after the treatment, and the length of stay in the hospital were recorded. The results of both treatment methods were compared statistically.&#x0D; RESULTS: A total of 23 patients and 26 kidney units over 13 years were retrospectively analyzed. Eighteen patients were male (78%); 5 were girls (22%). Ureteral tapering and ureteroneocystostomy (UNC) were performed with open surgery in 8 patients, while JJ stent was placed in 12 patients primarily by cystoscopy. In the urinary system ultrasonography (USS) performed at an average of 3 months after the treatment, hydronephrosis grades were observed to regress in 25 units. All patients recovered after surgery and there was no significant difference between the two treatment methods (p&gt; 0.05).&#x0D; CONCLUSION: In the treatment of primary obstructive megaureter (POM), endoscopic JJ stenting is as effective as ureteral reimplantation with open surgery. It may be considered more valuable due to the shorter hospital stay

Endoscopic treatment of primary obstructive megaureter with high pressure balloon dilation in infants

Ureteral reimplantation of the dilated ureter in infants is challenging; however, some patients with primary obstructive megaureter (POM) in this age group require intervention due to clinical or radiological progression. We sought to determine if high pressure balloon dilation (HPBD) can serve as a definitive treatment for POM in children under one year of age, or as a temporizing measure until later reimplantation. All patients from a single institution who underwent HPBD between October 2009 and May 2022 were retrospectively reviewed. Patients were excluded if older than 12 months or diagnosed with neurogenic bladder, posterior urethral valves, or obstructed refluxing megaureter. Patients with prior surgical intervention at the ureterovesical junction were excluded. Indications for surgery included progressive hydroureteronephrosis or urinary tract infection (UTI). Balloon dilation was performed via cystoscopy with fluoroscopic guidance, followed by placement of two temporary ureteral stents. Primary outcomes were improvement or resolution of megaureter and rates of subsequent reimplantation. Secondary outcomes included total number of anesthetics and postoperative UTIs. Fifteen infants with median age of 7.6 months (IQR3.8-9.7) underwent HPBD. Twelve (80%) patients were detected prenatally and 3 (20%) aftera UTI. Indication for surgery was progressivehydroureteronephrosis in 10 patients (67%) and UTI in five (33%). All had SFU grade 3 or 4 hydronephrosis on preoperative ultrasound and median distal ureteral diameter was 13mm. Median follow up was 2.9 years. Twelve (80%) succeeded with endoscopic treatment: 7 patients had an undetectable distal ureter on ultrasound at last follow-up, 5 were improved with median distal ureteral diameter of 7mm. Three patients (20%) required ureteral reimplantation due to progressive dilation, all with grade 4 hydronephrosis and distal ureteral diameters were 11, 15, and 21mm. Six patients (40%) required two anesthetics to complete endoscopic treatment. Among those, 4 patients required initial stent placement for passive dilation followed by a second anesthetic for HPBD weeks later. Two patients underwent repeat HPBD following postoperative proximal migration of the ureteral stents. All 15 patients had an additional anesthetic for removal of stents. Five patients (33%) were treated for a symptomatic UTI (4 febrile, 1 afebrile) with the stents indwelling but there were no UTIs in the group following stent removal. Balloon dilation is a practical option for treatment of POM in infants, and in most cases (80%) avoids subsequent open surgery (over median 2.9 years of follow-up).

High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review

ObjectiveWe aimed to evaluate the effectiveness and complication rates of endoscopic high-pressure balloon dilatation (HPBD) in treating primary obstructive megaureter (POM) in children based on current literature. Specifically, we wanted to clarify the evidence on the use of HPBD in children under one year of age.MethodsA systematic search of the literature was performed via several databases. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. The primary outcomes studied in this systematic review were the effectiveness of HBPD in relieving obstruction and reducing hydroureteronephrosis in children. The secondary outcome was to study the complication rate of endoscopic high-pressure balloon dilatation. Studies that reported one or both of these outcomes (n = 13) were considered eligible for inclusion in this review.ResultsHPBD significantly decreased both ureteral diameter (15.8 mm [range 2–30] to 8.0 mm [0–30], p = 0.00009) and anteroposterior diameter of renal pelvis (16.7 mm [0–46] to 9.7 mm [0–36], p = 0.00107). The success rate was 71% after one HPBD and 79% after two HPBD. The median follow-up time was 3.6 years (interquartile range 2.2–6.4 years). A complication rate of 33% was observed, but no Clavien–Dindo grade IV–V complications were reported. Postoperative infections and VUR were detected in 12% and 7.8% of cases, respectively. For children under one year of age, outcomes of HPBD seem to be similar to those in older children.ConclusionsThis study indicates that HPBD appears to be safe and can be used as the first-line treatment for symptomatic POM. Further comparative studies are needed addressing the effect of treatment in infants, and also long-term outcomes of the treatment. Due to the nature of POM, identifying those patients who will benefit from HPBD remains challenging.

ЭФФЕКТИВНОСТЬ БАЛЛОННОЙ ДИЛАТАЦИИ ВЫСОКОГО ДАВЛЕНИЯ ПРИ ПЕРВИЧНОМ ОБСТРУКТИВНОМ МЕГАУРЕТЕРЕ У ДЕТЕЙ РАННЕГО ВОЗРАСТА

The purpose of the research was to evaluate the efficacy of the high-pressure balloon dilatation (HPBD) of the vesicoureteral segment (VMS) as treatment of primary obstructive megaureter (POM) in pediatric patients aged 1 month to 2 years old and to identify the clear indications for its practical application. Materials and methods of the research: a single-center experimental uncontrolled open study was conducted in 2019 - 2022; 97 children with POM who underwent HPBP of the VMS: 47 boys and 50 girls. The study involved patients aged 1 month till 2 y/o. Patients underwent targeted retrograde pyelography and were assessed for the parameters of the zone of ureteral stenosis before and after the HPBP of the VMS: the length of the stenosis, its diameter and area. The follow-up period for the patients was 1 year. Results: the overall effectiveness of treatment was 92.8% as 7 ineffective cases were reported that required further reimplantation of the ureter. The most statistically significant predictors for the successful treatment were the length of the stenotic area of less than 1.7 mm, its diameter of more than 0.6 mm and the area of stenosis of less than 96.8%. Also, recovery was predicted if the difference in the diameter of the stenosis zone before and after the HPBP of the VMS was 2.4 mm, and the difference in the stenosis area before and after the HPBP of the VMS was above 49.8%. Conclusion: the HPBP of the VMS is an effective treatment for POM in infants. At the same time, the assessment of the obstruction zone during the HPBP is a necessary diagnostic procedure that serves as a reliable method for predicting the success of the treatment. Upon the receipt of parameters that cannot provide high probability of the positive result of treatment the authors suggest the ureter reimplantation.

Minimally invasive ureteral reimplantation or endoscopic management for primary obstructive megaureter: a narrative review of technical modifications and clinical outcomes.

Primary obstructive megaureter (POM) has various courses in different age populations. Although open ureteral reimplantation (OUR) remains the standard treatment for symptomatic POM, it is highly invasive with potential complications. In recent years, minimally invasive ureteral reimplantation (MIUR), including laparoscopic ureteral reimplantation (LUR) and robotic-assisted laparoscopic ureteral reimplantation (RALUR), and endoscopic management, such as double-J stent insertion, endoureterotomy and endoscopic balloon dilatation (EBD), have been utilized for POM in selected patients. However, few comparable studies between MIUR and endoscopic management have been published to date, and it remains unclear which surgical management is the optimal choice for POM in different age groups. This review provides a comprehensive perspective on technical development and clinical outcomes of MIUR and endoscopic management for POM in pediatric and adult populations. The PubMed and Web of Science databases were used to comprehensively search English language articles related to MIUR and endoscopic management for POM in pediatric and adult populations up to March 2022. The technical modifications and the relevant clinical outcomes were reviewed. MIUR with various technical modifications related to intracorporeal suturing and ureteroneocystostomy with anti-reflux techniques appears to be as safe and effective for POM in different age groups as the open procedure. Double-J stent insertion should be regarded as a temporary option for infants by achieving internal urinary drainage, as it may present limited success rates and various complications. Endoureterotomy using pure cutting current or laser appears to be a safer, easier, and less invasive alternative to open surgical management. While EBD has emerged as a definite treatment for POM in the pediatric population, it is debatable whether EBD can substitute for MIUR in adult patients. The safety and feasibility of MIUR and endoscopic management in patients from all age groups still need further investigation.

Endoscopic balloon dilatation for the treatment of primary obstructive megaureter

Endoscopic balloon dilatation (EBD) can be performed with different catheters and its durability is still controversial. This study aimed to compare long-term results of EBD performed <24 months of age using balloons of 4mm vs. 6mm in diameter. Retrospective study of consecutive patients with unilateral primary obstructive megaureter (POM) undergoing EBD <24 months of age by two surgeons from 01/2009 to 12/2020. The technique was consistent, but for balloon diameter, which was 4mm in group A vs. 6mm in group B. End-points included peri-operative complications, success rate (improving dilatation and non-obstructive drainage on 9-month scintigraphy), and long-term outcome (need for reimplantation and diameter of retrovesical ureter at last ultrasound). The procedure was completed in all planned patient. Group A included 15 patients and Group B 30 patients. Groups were not significantly different for age (p<0.09), gender (p <0.1), laterality (p <0.7), and preoperative median ureteral diameter (p =0.08). No perioperative complications occurred. Four group A patients required a cutting balloon to achieve a satisfactory dilatation of the vesicoureteral junction (p =0.009). After a median (range) follow-up of 70 (19-155) months, success rate was 73.3% vs. 83.3% (p =0.45), 4/15 group A and 5/30 group B patients required reimplantation within 2 years of EBD. In successful cases, median (range) ureteral diameter at last follow-up was 6 (0-17) mm vs. 5 (0-14) mm, which was significantly better than preoperative value (p =0.003 and p<0.001, respectively), but not significantly different (p =0.8) between groups. EBD is an umbrella term that encompasses many technical variations, which can be key for success. Although limited by the small numbers and the comparison of patients treated over two subsequent periods, this is the first study focusing on the role of balloon size. The diameter of the balloon did not influence significantly long-term results, but the 6mm balloon slightly increased the success rate of EBD to 83.3% and eliminated the need for cutting balloons to achieve a satisfactory dilatation.

Ureteral Reimplantation for Primary Obstructive Megaureter in Pediatric Patients: Is It Time for Robot-Assisted Approach?

Objective: To compare open and robotic approach for treatment of Primary Obstructive Megaureter (POM) in a series of pediatric patients. Materials and Methods: Medical records of all patients who had undergone ureteral reimplantation for POM at our institution, between January 2016 and December 2019, were retrospectively collected and analyzed. Open (Group B) and robotic (Group A) approach were compared. Success was defined as reduction of anteroposterior diameter of pelvis and ureter on postoperative ultrasound scan. Surgical complications were reported according to the Clavien-Dindo Classification. Esthetic results were compared through the Vancouver Scar Scale. Results: Out of 23 patients, 11 belonged to Group A (5M and 6F) and 12 to Group B (9M and 3F). Median age at diagnosis was 38 months in Group A and 46 months in Group B (P = .69). Operative times were comparable (150' Group A and 140' Group B; P = .35), but the hospital stay was significantly shorter in the robotic group (P < .01). Success rate was comparable: 90.9% in Group A and 91.7% in Group B, respectively (P = .95). Incidence of early complications was 9.1% in Group A (grade IIIB) and 8.3% in Group B (grade II) (P = .95). Esthetic evaluation obtained a median score of 1 in Group A and 3 in Group B (P < .01). Conclusions: Our preliminary experience shows that robotic reimplantation can be a safe option in the treatment of POM in pediatric patients with clinical outcomes comparable to the open technique.

High-pressure balloon dilatation for the treatment of primary obstructive megaureter: is it the first line of treatment in children and infants?

To evaluate the efficacy of high-pressure balloon dilatation (HPBD) as treatment of primary obstructive megaureter (POM) in paediatric patients, we analysed the data of our institute from June 2018 to September 2019. 14 patients, aged 5 months to 5 years, with POM were treated with HPBD. All patients had a distal ureter dilatation greater than 7 mm associated with obstructive features on a mercaptoacetyl triglycine-3 diuretic renogram scan, and a voiding cystourethrogram without vesicoureteral reflux. HPBD was performed in 12 patients, whereas 2 patients (14%), aged 5 and 6 months, required open surgical treatment because of failure to pass the balloon catheter through the vesicoureteral junction. The procedure was performed with a 5 Fr balloon catheter for two cycles of 5 minutes each at 17 atm. A double-J stent and a urinary catheter were inserted at the end of procedure in all patients. No operative complications or symptoms or recurrence were recorded in our series. The patients were generally discharged 24 hours after surgery. All the patients showed an improvement on ultrasonography at the postoperative follow-up, with no evidence of obstruction. During the procedure a clear stenotic ring was identified in 10 of the 12 patients, which disappeared in all 10 cases after the HPBD technique. Based on our experience, HPBD may be considered the first-line surgical approach in the treatment of POM in children, avoiding bladder surgery in most cases.

High-pressure balloon dilatation in children: our results in 30 patients with POM and the implications of the cystoscopic evaluation.

Primary Obstructive Megaureter (POM) is a common cause of hydronephrosis in children with spontaneous resolution in most cases. High-Pressure Balloon Dilatation (HPBD) has been proposed as a minimally invasive procedure for POM correction in selected patients. The aim of the paper is to review our experience with HPBD in patients with POM. We performed a retrospective study in a single Centre collecting data on patients' demographics, diagnostic modalities, surgical details, results and follow-up. In particular, the endoscopic aspect of the orifice permitted the identification of 3 patterns: adynamic ureteral segment, stenotic ureteric ring and pseudoureterocelic orifice. We performed HPBD in 30 patients over 6 years. We had 23 patients with adynamic distal ureteral segment (type 1), 4 with stenotic ring (type 2) and 3 with ureterocelic orifice (type 3). In 3 patients (10%) the guidewire did not easily pass into the ureter requiring ureteral stenting or papillotomy. Post-operative course was uneventful. Five patients (3 pseudoureterocelic) required open surgery during follow-up. HPBD for the treatment of POM is a safe and feasible procedure and it can be a definitive treatment of POM. Complications are mainly due to double J stent and none of our patients had symptoms related to vescico-ureteral reflux. The aspect of the orifice, identified during cystoscopy, seems to correlate with the efficacy of the dilatation: type 1 and 2 are associated with good and excellent results respectively; type 3 do not permit dilatation in almost all cases requiring papillotomy. HPBD can be performed in selected patients of all paediatric ages as first therapeutic line. The presence of a pseudoureterocelic orifice or long stenosis might interfere with the ureteral stenting and seems associated with worse outcomes.

Treatment of primary obstructive megaureter in children using minimally invasive technologies

Treatment of primary obstructive megaureter in children using minimally invasive technologies

Treatment of primary obstructive megaureter in children using minimally invasive technologies

Introduction. The final formation of the child's functional systems completed during postnatal ontogeny. To create optimal conditions for the functioning of the body is necessary either to decrease the level of functional requirements to the immature system, or the creation of new operating conditions under which the extended maturation time factor.&#x0D; Relevance. Currently, the most common treatment for obstructive uropathies is surgical treatment. To create optimal conditions for the functioning of the body, it is necessary either to reduce the level of requirements for an immature functional system, or to create new functioning conditions under which the ripening time factor is extended.&#x0D; Objective: Rationale and introduction of minimally invasive endoscopic draining techniques aimed at restoring urodynamics by using a PVC intraluminal drainage (stent).&#x0D; Materials and methods. The possibility of stenting with determination of the size of the ureteric orifice was investigated. The study involved 32 children aged from birth to three years. A retrospective analysis of previously treated 41 patients with obstructive ureterohydronephrosis was performed.&#x0D; Results. The study found that the optimal age for endoscopic correction of the intramural ureter is up to 3 months of life, when telescopic bougienage with dilation of the intramural compartment of the compromised ureter can be performed with calibration of the ureteric orifice and stent of the ureter with a corresponding stent.&#x0D; Retrospective analysis of previously treated patients allowed us to determine the same dependence. Thus, out of 41 patients with obstructive ureterohydronephrosis positive result was achieved in 29 children (70.73%) up to 1 year and 6 (14.63%) over 1 year. The impossibility of performing endoscopic correction of the orifice and stenting of the ureters in the age group up to 1 year was noted only in 1 patient (2.43%), whereas in the group from 1 year to 3 years - in 5 patients (12.19%).&#x0D; Conclusions. The proposed tactics of treatment of obstructive uropathy in children has advantages in terms of open surgical techniques in the technical simplicity, minimally invasive, maximum physiological, reducing the incidence of postoperative complications. It should be remembered that the effectiveness of endoscopic stenting of the lower parts of the ureter depends on the age of the child.

MP71-08 MICRO-LAPAROENDOSCOPIC SINGLE SITE VESICO-URETERAL REIMPLANTATION WITH LICH–GREGOIR APPROACH IN CHILDREN WITH PRIMARY OBSTRUCTIVE MEGAURETER

You have accessJournal of UrologyPediatrics: Upper Urinary Tract Disorders and Fetal Urology (MP71)1 Apr 2020MP71-08 MICRO-LAPAROENDOSCOPIC SINGLE SITE VESICO-URETERAL REIMPLANTATION WITH LICH–GREGOIR APPROACH IN CHILDREN WITH PRIMARY OBSTRUCTIVE MEGAURETER Dengxin Fan* Dengxin Fan*Dengxin Fan* More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000951.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite scattered ureteral cases in adults, no reports of pediatric LESS ureteral reimplantation or ureteroureterostomy exist in the literature.We report our experience in the treatment of primary obstructive megaureter (POM) by micro-laparoendoscopic single site (micro-LESS) vesico-ureteral reimplantation with Lich–Gregoir approach in children. METHODS: From January 2015 to October 2019,a total of 28 children (22 males and 6 females, aged 6 months to 8.4 years) underwent micro-LESS vesico-ureteral reimplantation with Lich–Gregoir technique. The 0.5-1 cm incision along the umbilical folds was used as the surgical channel in all cases. All procedures were performed with a 5mm laparoscope, a homemade gloves port, standard 3- or 5-mm laparoscopic instrumentation, articulating instruments, and crossed manipulation way.The postoperative follow-up included abdomino-pelvic ultrasound at 3 months after surgery, and CT urography at 6 months and 1 year after surgery. RESULTS: All cases was successfully completed without the need for traditional laparoscopic or open conversion; there were no major intraoperative complications. The mean operative time was 120.5 min (range 115-155 min). The postoperative ultrasound demonstrated improvement of the dilatation of the pelvicalyceal system and ureters in all patients, and the surgical scar was invisible after 3 months. CONCLUSIONS: The results of our study suggest that micro-laparoendoscopic single site (micro-LESS) vesico-ureteral reimplantation with Lich–Gregoir approach in children is feasible, and it seems to be safe and effective in the treatment of primary obstructive megaureter (POM). Furthermore, the patients tolerated the surgery well and they appreciated its outstanding cosmetic outcomes. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1067-e1067 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dengxin Fan* More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic Extravesical Reimplantation in Children with Primary Obstructive Megaureter.

Introduction: Conservative management of primary obstructive megaureter (POM) appears as the best option in patients with adequate ureteral drainage. Nevertheless, surgical intervention is indicated in cases of recurrent urinary tract Infections (UTIs), deterioration of split renal function, and significant obstruction. The gold standard includes: Ureteral reimplantation with or without tapering by open approach. Our objective is to report our results in the treatment of POM by Laparoscopic-Assisted Extracorporeal Ureteral Tapering Repair (EUTR) and Laparoscopic Ureteral Extravesical Reimplantation (LUER) and to evaluate the efficacy and security of this procedure. Materials and Methods: From January 2011 to January 2018 a retrospective study was carried out by reviewing the clinical records of 26 patients diagnosed with POM. All patients underwent laparoscopic ureteral reimplantation following Lich Gregoir technique. In cases of ureteral tapering, an EUTR was performed with Hendren technique. Results: In all patients LUER and EUTR were performed without conversion. No ureteral tapering was necessary in six patients. There were no intraoperative complications. At 3 months in postoperative, 1 patient presented a febrile UTI, and subsequently, a vesicoureteral reflux (VUR) grade III was diagnosed by voiding cystourethrogram. In this case, a redo laparoscopic surgery was performed. After long-term follow-up, all patients were asymptomatic without recurrence of POM or VUR. Conclusion: Laparoscopic-assisted EUTR and LUER following Lich Gregoir technique for POM constitutes a safe and effective option, with a success rate similar to that of open procedure. Nevertheless, larger randomized prospective trials and long-term follow-up are required to validate this technique.

Primary obstructive megaureter: a domain of conservative treatment

The term "megaureter" is an entirely descriptive designation for a number of different entities. It is crucial to distinguish between primary and secondary forms of megaureter and between obstructive and/or refluxive forms. In the majority of cases, there is a primary obstruction in the terminal ureterovesical segment. The treatment of primary obstructive megaureter has changed fundamentally over the last 3 decades. Whereas ureteral reimplantation was the treatment of choice in the past, conservative treatment is now preferred in 85 to 90 % of patients. With the advent of endoscopic balloon dilatation, a modern, minimally-invasive treatment option has become an alternative to ureteral reimplantation in selected patients. However, due to the possibility of postoperative VUR (vesicoureteral reflux), it is necessary to emphasize that this option should not weaken the generally strict indication for surgical treatment of primary obstructive megaureter.

Efficacy of robot-assisted laparoscopic ureteral reimplantation for primary obstructive megaureter in children

Objective To evaluate the clinical efficacy of robot-assisted laparoscopic ureteral reimplantation (RAUR) for primary obstructive megaureter (POM) in children. Methods Twenty-one patients who underwent RAUR for POM in Bayi Children’s Hospital between 2017 April and 2018 April were retrospectively analyzed. The study population consisted of 15 boys and 6 girls aged between 2 months and 11 years. Ten patients had left POMs, 9 had right POMs and two had bilateral POMs. All patients were preoperatively diagnosed with a POM based on urinary system ultrasonography, magnetic resonance urography, and diuretic renal dynamic imaging. Our main technique key steps include: Under general anesthesia, the patients were placed in a Trendelenburg position approximately 40 degrees from the horizon. An 8.5-mm camera port was placed at the level of the umbilicus. Followed by two 5-mm robotic Trocars placed under direct vision 6 cm to the camera port separately, a 5-mm assistant port was placed on the right upper abdominal quadrants which was located 3 cm from the camera and robotic port. The ureter was identified at the pelvic brim. The peritoneum covering the ureter was incised and the ureter was mobilized to the level of the vesico-ureteric junction. The bladder was filled with 60 ml saline and a 5 cm length and 1.5 cm wide submucosal detrusor tunnel was created. The ureter was transected at the bladder mucosa and the narrowed ureteral segment was discarded. The ureteroneocystostomy was performed using 6-0 absorbable suture. Dissecting the perivesical fascia appropriately and using down-top suturing approach, use of an apical stay stitch, and incorporation of the ureteral adventitia during detrusorraphy. Postoperative complications were analysed using the Clavien-Dindo classification. Success was defined as symptomatic relief, decreased hydronephrosis on ultrasound and no evidence of vesicoureteral reflux on voiding cystourethrography. Results All surgeries were successfully completed without conversion and no intra-operative complication was encountered. The mean operative time was 117.6±18.1(89-165)min, the mean estimated blood loss was 11.9±4.3(5-25)ml, the abdominal drainage tubes were removed after a mean of 4.9±1.1(3-8)days, and the mean postoperative hospital stay was 6.3±1.3(4-10) days. Postoperative complications (Clavien Ⅰ-Ⅱ) occurred in 9.5% (two patients had recurrent urinary tract infections postoperatively) children, no grade Ⅲ-Ⅳ complication was observed. The pre-operative symptoms in all patients disappeared. One patient had grade Ⅱ VUR on VCUG, who were followed conservatively. Ultrasound at postoperative follow-up showed that the hydronephrosis was disappeared in 20 ureters and significantly decreased in 3 ureters. The success rate was 95.7% at a mean follow-up of 16.3±4.0(10-23)months. Conclusion RAUR is a safe and feasible option for the treatment of POM in children with higher success rate and lower complication rate. Key words: Laparoscopes; Robot-assisted; Ureter reimplantation; Primary obstructive megaureter; Children

High Pressure Balloon Dilatation of Primary Obstructive Megaureter in Children: A Multicenter Study.

Aim of the Study: We described the initial experience of four referral centers in the treatment of primary obstructive megaureter (POM) in children, by high-pressure balloon dilatation (HPBD) of the ureterovesical junction with double JJ stenting. We managed a retrospective multicenter study to assess its effectiveness in long-term.Methods: We reviewed the medical records of all children who underwent HPBD for POM that require surgical treatment from May 2012 to December 2017 in four different institutions. The primary outcome measured was ureterohydronephrosis (UHN) and its degree of improvement after the procedure. Secondary outcomes were postoperative complications and resolution of preoperative symptomatology.Main Results: Forty-two ureters underwent HPBD for POM in 33 children, with a median age of 14.7 months – (range: 3 months −15 years). Ureterohydronephrosis improves in 86% of ureters after one endoscopic treatment. Three cases required a second HPBD. Four patients required surgical treatment for worsening of UHN after endoscopic treatment. The post-operative complication rate was 50% (21 ureters). In 13 cases (61%), they were related to double J stent. The median follow-up was 24 months (2 months −5 years) and all patients were symptom-free.Conclusion: We reported the first multicenter study and the largest series of children treated with HPBD, with an overall success rate of 92%. Endoscopic treatment can be a definitive treatment of POM since it avoided reimplantation in 90% of cases. Complications are mainly due to double J stent.

Long-Term Outcomes in Primary Obstructive Megaureter Treated by Endoscopic Balloon Dilation. Experience After 100 Cases.

Aim: To assess long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation (EBD) in the largest series reported.Patients and Methods: Hundred POM in 92 consecutive patients were treated by EBD between years 2004 and 2016. A total of 79 POM (73 patients) with more than 18 months of follow-up after treatment have been analyzed. EBD of the vesicoureteral junction was performed with semicompliant high-pressure balloon catheters (2.7FG) with minimum balloon diameter of 5 mm, followed by temporary Double-J stent placement. Follow-up protocol included periodical clinical reviews, US and MAG-3 renogram scans.Results: Median age at surgery was 4 months (15 days−3.6 years), with median operating time of 20 min (10–60) and hospital stay of 1 day (1–7). Initial renal function was preserved in all patients with significant improvement in renal drainage on the MAG-3 diuretic renogram after endoscopic treatment (p < 0.001 T-test). Significant post-operative differences were observed in hydronephrosis grade and ureteral diameter that were maintained in the long-term (p < 0.001 T-test). Endoscopic approach of POM had a long-term success rate of 87.3%, with a mean follow-up of 6.4 ± 3.8 years. Secondary VUR was found in 17 cases (21.5%), being successfully treated by endoscopic subureteral injection in 13 (76.4%). Nine cases developed long-term re-stenosis (12.2%) that were successfully treated with a new EBD in 8. Endoscopic management of POM failed in 10 cases (12.7%) that required ureteral reimplantation. Five were early failures (4 intraoperative technical problems and 1 double-J stent migration with severe re-stenosis), and 5 long-term (4 persistent VUR and 1 re-stenosis recurrence).Conclusion: EBD has shown to be an effective treatment of POM with few complications and good outcomes at long-term follow up. Main complication was secondary VUR that could also be treated endoscopically with a high success rate. In our opinion, EBD may be considered first-line treatment in POM.