Excision Of Ureterocele Research Articles

V02-12 URETEROCELE EXCISIONAL TECHNIQUE USING THULIUM LASER

You have accessJournal of UrologyCME1 Apr 2023V02-12 URETEROCELE EXCISIONAL TECHNIQUE USING THULIUM LASER Jordan Krieger, Ali Antar, and Margaret Knoedler Jordan KriegerJordan Krieger More articles by this author , Ali AntarAli Antar More articles by this author , and Margaret KnoedlerMargaret Knoedler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroceles are cystic dilations of the distal ureter at its insertion site into the bladder and occur in 1 in 1000 births. Endoscopic intervention is minimally invasive and can alleviate obstruction in >95% of cases. The Thulium laser is a relatively new laser with a 1940 nm wavelength and a four times higher absorption in water than the Holmium laser. This theoretically leads to better tissue ablation and hemostasis. Our objective is to demonstrate the safety and efficacy of Thulium laser use for excision of ureteroceles. METHODS: This is a 22-year-old patient with normal renal function and a complex urologic history including bilateral duplicated collecting systems, vesicoureteral reflux with bilateral deflux injections, a right-sided ureterocele, and recurrent urinary tract infections resulting in hospitalizations for pyelonephritis. She was taken to the operating room for an endoscopic right ureterocele excision using Thulium laser. We used the Soltive SuperPulsed Thulium Fiber Laser (200 micron) with settings of 1 joule (J) for pulse energy and 20 hertz for frequency (20 watts). Total energy used was 2756 J. Tissue ablation and hemostasis were excellent, and no additional time was required at the end of the case to obtain hemostasis from the excised edges. She discharged the same day without issues. RESULTS: Six weeks later the patient followed-up in our clinic with a renal ultrasound demonstrating no hydronephrosis and a decompressed ureterocele. She denied any flank pain or recurrent infections. CONCLUSIONS: Thulium laser excision is a safe and efficacious treatment option for management of symptomatic ureteroceles. It showed excellent tissue ablation and hemostatic properties. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e172 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jordan Krieger More articles by this author Ali Antar More articles by this author Margaret Knoedler More articles by this author Expand All Advertisement PDF downloadLoading ...

V03-06 SINGLE PORT ROBOTIC-ASSISTED TRANSVESICAL EXCISION OF BILATERAL URETEROCELES WITH URETERAL RE-APPROXIMATION

You have accessJournal of UrologyCME1 Apr 2023V03-06 SINGLE PORT ROBOTIC-ASSISTED TRANSVESICAL EXCISION OF BILATERAL URETEROCELES WITH URETERAL RE-APPROXIMATION Labeeqa Khizir, Juliana E. Kim, Alain Kaldany, Sai Krishnaraya Doppalapudi, and Sammy E. Elsamra Labeeqa KhizirLabeeqa Khizir More articles by this author , Juliana E. KimJuliana E. Kim More articles by this author , Alain KaldanyAlain Kaldany More articles by this author , Sai Krishnaraya DoppalapudiSai Krishnaraya Doppalapudi More articles by this author , and Sammy E. ElsamraSammy E. Elsamra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The patient is a 35-year-old female with prior medical history of recurrent urinary tract infections (UTI), who presented to the emergency department for severe right abdominal pain with difficulty urinating. On physical exam, the patient was found to have a non-tender prolapsed ureterocele per urethra causing transient bladder outlet obstruction. Subsequent MRI of the pelvis showed severe right-sided hydroureter with ectopic insertion of the right ureter at the bladder neck and associated ureterocele, as well as moderate left-sided hydroureter with associated ureterocele. Here, we present a minimally invasive and definitive robotic repair of bilateral ureteroceles. METHODS: The patient was prepped and draped in the usual sterile fashion. An anterior cystotomy measuring approximately 5 cm was made, and the bladder was emptied. A single port robotic access device was then placed directly into the bladder. The patient was placed in a slight Trendelenburg position and the robot was docked. Surgical footage highlights include: bilateral ureterocele excision using electrocautery, creation of a urothelial defect on the right ureter due to excision of the large ureterocele, ureteral re-approximation, and affixation of the ureter. The cystotomy was closed and the bladder was noted to be watertight. RESULTS: Total operative time was 123 minutes. The patient recovered with unremarkable post-operative course and was discharged on same day of surgery. Post-operative imaging showed resolution of symptoms and bilateral hydronephrosis thereafter. CONCLUSIONS: Single-port transvesical approach provided a better vantage point for robotic repair compared to more traditional endoscopic approaches. This approach also allowed for the mucosa to be oversewn easily, mitigating risk of future stricture formation or ureterocele recurrence. In addition, higher insufflation pressure within bladder allowed ureteroceles to be collapsed, yet visible, and aided in excision. In summary, single-port robotic-assisted transvesical excision with ureteral re-approximation allowed for minimally invasive and definitive repair of bilateral ureteroceles. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e247 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Labeeqa Khizir More articles by this author Juliana E. Kim More articles by this author Alain Kaldany More articles by this author Sai Krishnaraya Doppalapudi More articles by this author Sammy E. Elsamra More articles by this author Expand All Advertisement PDF downloadLoading ...

Duplex Kidney Anomalies and Associated Pathologies in Children: A Single-Center Retrospective Review.

Introduction: Duplex renal collecting systems are one of the most common congenital anomalies of the urinary tract. The exact prevalence of this anomaly is difficult to ascertain because most patients are asymptomatic, and the abnormality is frequently detected incidentally. The aim of this study is to retrospectively review the demographic characteristics and different clinical presentations, related pathology, and treatment methods of patients with duplex system anomaly who applied to our institution, with a literature review.Methods: This is a retrospective study, performed at the Department of Pediatric Urology and Pediatric Surgery, Umraniye Training and Research Hospital, a tertiary center, from 2010 to 2021. Age, gender, presenting symptoms, and associated anomalies were determined in all patients. Asymptomatic patients with variants of duplex kidney anomaly detected incidentally did not require any surgical intervention. Necessary surgical interventions were performed depending on the pathologies of other symptomatic patients associated with duplex kidney anomaly variants.Results: A total of 239 patients had duplex systems. The patients were divided into two groups according to their age, 0-24 months (newborn and infant) and over 24 months. There were 45 (18.8%) patients in the 1st group and 194 (81.1%) patients in the 2nd group. It was seen that the most common symptom in 85 (35.6%) patients was urinary tract infection (UTI). It was observed that 5 (2%) patients had no symptoms and were detected during routine screening. When comorbidities detected with the duplex system were examined, the most common ones were antenatal hydronephrosis 23 (9.6%). Ureterocele excision was performed in ten patients, laparoscopic heminephrectomy was performed in six patients, and ureteroneocystostomy was performed in one patient.Conclusions: It is important that magnetic resonance urography (MRU) duplex renal collecting systems, which is a current imaging method used in the evaluation of the duplex system, provide detailed information about the morphology and function and are useful in the evaluation of associated anomalies. Diagnosis and treatment before it becomes symptomatic or results in further kidney damage are important for the preservation of renal function in advanced follow-ups.

Coexistence of multiple ureteral and ureterocele stones in a patient

BackgroundUroterocele causes atony and stagnation in the ureter, thus predisposing the patient to stone formation. Multiple calculi in uroteroceles are common in adults but very rare in children.Case presentationWe describe the case of a 3-year-old boy who presented with hematuria and was found to have multiple ureteral and ureterocele stones. The diagnosis was made during endoscopic lithotripsy. A holmium/yttrium–aluminum–garnet (Ho–YAG) laser was used to excise the uroterocele and for lithotripsy.ConclusionsIn appropriate cases, minimally invasive techniques, for example, Ho–YAG laser lithotripsy and ureterocele excision may be preferred.

Giant ureterocele management in an adult male: A rare case report

Ureterocele is dilatation of lower ureter at its entry into the urinary bladder. It is classified into the single or duplex system and acquired or congenital. Acquired type is rare and seen in adults. We report the case of a 23-year-old male presented with voiding lower urinary tract symptoms and intermittent flank pain. He had a history of frequent spontaneous stone passage with right colicky pain 2 years back. On ultrasonogram and magnetic resonance urogram, diagnosis was made as right renal hydronephrosis with hydroureter due to right side giant intravesical ureterocele. The patient was managed by endoscopic transurethral incision and excision of ureterocele. It is the first case ever reported in the literature, where in giant ureterocele was completely removed by total endoscopic approach.

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

ObjectiveTo 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. MethodsAfter 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. ResultsTwenty-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. ConclusionFor 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.

Ureterocele in newborns, infants and children: Ten year prospective study with primary endoscopic deroofing and double J (DJ) stenting

AimTo evaluate the success of endoscopic deroofing with double J (DJ) stenting as a primary treatment modality of uncomplicated ureterocele. Patients and methodsAll babies with uncomplicated ureterocele referred to us between 2005 and 2015 were to be prospectively recruited into the study without any exception. The preoperative management would include ultrasound KUB on a fixed protocol, micturating cystourethrogram, DTPA scan and MRU (magnetic resonance urography) or IVP (intravenous pyelography). Those who had non-obstructing ureterocele were to be followed conservatively. The indications for operative intervention were to be obstructed ureterocele, bladder outlet obstruction, recurrent UTI or progressive renal scarring. They were then to be taken for cystoscopy in diuretic phase for endoscopic deroofing and DJ stenting with 9F resectoscope. Four weeks later, the DJ stent was to be removed after examining the deroofing in each patient. They were then followed up for future development of symptoms and need for secondary surgery with anatomical and functional imaging as necessary. ResultsForty three consecutive patients (47 ureterocele units) with ureterocele were recruited into the study between 2005 and 2015. Thirty four patients were managed by endoscopic first approach with ureterocele deroofing and DJ stenting. Four babies were asymptomatic and did not show obstructed drainage pattern on DTPA and hence were managed conservatively and kept on follow-up. Four patients underwent primary open surgery and reconstruction because of presentation with complications. Ectopic ureteroceleThere were 17 patients with ectopic ureterocele. Thirteen underwent primary endoscopic deroofing. Three underwent open surgery and one underwent robotic bilateral ureterocele excision and ureteric reimplantation. Eight children out of thirteen are completely asymptomatic after the endoscopic incision. On ultrasound evaluation 8/13 have resolution of the hydronephrosis and 5/13 have stable hydronephrosis with no increase in dilatation. None of these 13 children have required a second endoscopic procedure for inadequate decompression of the ureterocele. None of the 13 patients have any voiding difficulty or incontinence. 2/13 cases with recurrent UTI and persistent symptoms, required secondary surgery. This constituted 15% secondary surgery in the ectopic ureterocele category. Orthotopic ureteroceleThere were 21 patients out of 22 with orthotopic ureterocele who underwent endoscopic deroofing. Six out of these 21 patients had episodes of UTI, of which three had resolution of the reflux and two had downgrading of reflux. One child continued to have recurrent UTI and needed a laparoscopic nephroureterectomy. Eighteen children are completely asymptomatic after the initial endoscopic deroofing. The rate of secondary surgery was 4.7% in orthotopic ureterocele group, where nearly 50% have more than five years follow-up. None of our patients who are more than five years, have had any urinary incontinence or voiding dysfunction. All patients remain on follow-up from 6months to 10years (median 5years). ConclusionAt this stage of our study with median follow-up of 5years (6months–10years), we suggest that primary endoscopic deroofing with DJ stenting for obstructing ureterocele is the best initial approach for adequate decompression and reducing the rate of secondary surgery.

Management of duplex‐system ureterocele

To analyse different treatment modalities, functional outcome and continence in children treated for duplex-system ureterocele and to review the relevant literature. The medical records of patients with duplex-system ureterocele treated between 2001 and 2011 were reviewed retrospectively. 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. 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.

V541 ROBOTIC INTRAVESICAL URETEROCELE EXCISION

You have accessJournal of UrologyPediatrics1 Apr 2012V541 ROBOTIC INTRAVESICAL URETEROCELE EXCISION Brian Rosman, Courtney Rowe, Alan Retik, and Hiep Nguyen Brian RosmanBrian Rosman Boston, MA More articles by this author , Courtney RoweCourtney Rowe Boston, MA More articles by this author , Alan RetikAlan Retik Boston, MA More articles by this author , and Hiep NguyenHiep Nguyen Boston, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.615AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ureterocele excision is a procedure that is typically performed in an open fashion. The robotic approach has many challenges associated with it, as well as many advantages. This video will demonstrate several techniques, including bladder fixation and port closure techniques, which can make a robotic approach a feasible, safe, and effective option for ureterocele excision. METHODS A suitable patient was selected that had a large enough bladder, clinical indication for ureterocele excision, and interest in a robotic approach. The patient had a right sided congenital multicystic kidney without much function, and underwent a right nephroureterectomy previously. He had recurrent episodes of hematuria, and a ureterocele was identified. The ureterocele was a simple orthotopic stenotic ureterocele, seen on VCUG as a filling defect, and confirmed cystoscopically. The decision was made to definitively treat the ureterocele after cystoscopic de-roofing failed to relieve the symptoms. After cystoscopy was performed, two stay sutures were placed through the rectus muscle and all bladder layers to hitch the bladder to the abdominal wall during the procedure. This prevented the bladder from falling away from the abdominal wall during surgery, and pulling out the robotic ports. The ports were placed, along with a Veress needle. The bladder was drained of urine and insufflated, and the camera and instruments placed. The ureterocele was identified, and excised with monopolar scissors. The defect in the detrusor muscle was closed in two layers. This patient had a previous nephroureterectomy on the ipsilateral side, therefore no re-implant was required. The ports were removed, and the port holes closed using a “suture suspension disc”. This disc was used before port placement, and acts as a stencil for proper port and suture placement, ensuring that the preplaced sutures are able to tightly close the port site. RESULTS This patient did very well post-operatively, with minimal pain, quick return to eating and drinking and ambulating, and was discharged from the hospital 24 hours after his procedure. He had no further hematuria or obstructive symptoms on repeat follow-up examinations. CONCLUSIONS With the techniques detailed in this video, the difficulties of robotic ureterocele excision can be easily overcome, allowing the benefits of the minimally invasive approach to be applied to intravesical ureterocele excision. Robotic intravesical ureterocele excision is a safe and effective procedure. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e222 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Rosman Boston, MA More articles by this author Courtney Rowe Boston, MA More articles by this author Alan Retik Boston, MA More articles by this author Hiep Nguyen Boston, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Intravesical Ureterocele Excision

Introduction: Ureterocele excision is a procedure that is typically performed in an open fashion. The robotic approach has many challenges associated with it, as well as many advantages. This video will demonstrate a robotic intravesical ureterocele excision, highlighting several novel techniques to aid the procedure, including bladder fixation to the rectus muscle and a unique approach to effective and watertight port closure, which can make a robotic approach a feasible, safe, and effective approach to ureterocele excision. Methods: A suitable patient was selected who had a large enough bladder, clinical indication for ureterocele excision, and interest in a robotic approach. The patient had congenital multicystic kidney without much function, and underwent a right nephroureterectomy previously. He had recurrent episodes of hematuria, and a ureterocele was identified via voiding cystourethrogram (VCUG). The ureterocele was a simple orthotopic stenotic ureterocele, seen on VCUG as a filling defect, and confirmed cystoscopically. The decision was made to definitively treat the ureterocele after an attempt at cystoscopic de-roofing failed to relieve the symptoms. After initial cystoscopy was performed, two stay sutures were placed through the rectus muscle and all bladder layers to hitch the bladder to the abdominal wall during the procedure. This prevented the bladder from falling away from the abdominal wall during surgery, and pulling out the robotic ports, and was performed under cystoscopic observation. The robotic ports were placed, along with a Veress needle. The bladder was drained of urine and insufflated, and the camera and instruments placed. The ureterocele was identified, and excised with monopolar scissors. The defect in the detrusor muscle was closed in two layers with vicryl and chromic gut sutures. This patient had a previous nephroureterectomy on the ipsilateral side; therefore, no re-implant was required after the excision. The ports were removed, and the port holes closed using a suture suspension disc. This disc was used as a guide before port placement, and acts as a stencil for proper port and suture placement, ensuring that the preplaced sutures are in the correct position to be able to tightly close the port site. Results: This patient did very well postoperatively, with minimal pain and quick return to eating and drinking and ambulating, and was discharged from the hospital 24 hours after his procedure. He had no further hematuria or obstructive symptoms on repeat follow-up examinations. Conclusions: With the techniques detailed in this video, the difficulties of robotic ureterocele excision can be easily overcome, allowing the benefits of the minimally invasive approach to be applied to intravesical ureterocele excision. Robotic intravesical ureterocele excision is a safe and effective procedure. The authors have no professional or financial conflicts of interest to disclose regarding this video or procedure. Runtime of video: 7 mins 03 secs

Laparoscopic Extravesical Transperitoneal Approach Following the Lich–Gregoir Procedure in Refluxing Duplicated Collecting Systems: Initial Experience

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Nephropathy with renal scarring is still the most concerning issue in VUR. Surgical correction to eliminate VUR is an important part of its management and this need is increasing for duplicated collecting systems (DCS). Laparoscopy may have a place in the treatment of VUR. We report our initial experience in the treatment of refluxing DCS by laparoscopic extravesical transperitoneal approach (LETA) following Lich-Gregoir technique. The aim of this study was to describe the evolution and evaluate the results and benefits of this technique. Between August 2007 and January 2010, 60 renal units in 43 children with VUR and deterioration of renal function on isotope renography were treated with LETA following the Lich-Gregoir procedure. Twelve patients had refluxing DCS in a lower polar system; three of them had bilateral VUR. Three cases of refluxing DCS were associated to obstruction. Two of them presented an ectopic ureterocele with adequate split renal function and another had an ectopic ureterocele with complete deterioration of upper polar renal function. Their mean age was 36 months (range: 15-80 months). The mean surgical time was 90 minutes (38-140 minutes) in unilateral and 144 minutes (120-200 minutes) in bilateral VUR including cystoscopy. All procedures were successfully completed laparoscopically and the reflux was corrected in all patients. One-stage laparoscopic heminephroureterectomy with excision of ureterocele and ureteric reimplantation was done in 1 case, and ureterocele excision and ureteric reimplantation by LETA were done in 2 cases. The mean hospital stay was 27 hours. A cystogram was performed systematically in all patients at 45 days postoperatively; none of them presented recurrence of VUR. The follow-up period was 11 months (range: 2-24 months), without recurrence of VUR. LETA following the Lich-Gregoir procedure in refluxing DCS is a safe and effective approach even in unilateral, bilateral simultaneous, and split renal function in duplicated systems. When refluxing DCS is associated with obstruction and total deterioration of upper polar function, heminephroureterectomy with excision of ureterocele and ureteric reimplantation can be safely and effectively performed in a single-stage laparoscopic procedure, which minimizes the hazards of traditional open surgical reconstruction. A shorter hospital stay, decreased postoperative discomfort, reduced recovery period, and a low morbidity to resolve VUR in DCS are the benefits of this technique, with success rates similar to the open technique.

Ectopic ureteroceles in duplex systems: Long-term follow up and ‘treatment-free’ status

Objective Definitive treatment of ectopic ureterocele (EU) implies that no further surgery or prophylactic antibiotic is needed. The literature is unclear on which interventions render a child ‘treatment free’. Materials and methods Thirty (23 female, seven male) patients presented between 1984 and 2000. Follow up ranged from 5 to 15 years (mean: 7). Presenting reasons were: urinary tract infection in 18 (16 females, two males; age: 17 < 6 months, one 2 years), prenatal ultrasound in 11 (seven females, four males), and renal failure in one (male, aged 3 weeks). Results Treatment was as follows. No intervention, three (10%). Single procedure, eight (27%): five hemi-nephrectomy (HN), two transurethral incisions (TUI), one excision and re-implantation (E&R). Two procedures, 14 (47%): first procedure 10 TUI, 4 HN; second procedure 13 E&R, 1 TUI. Three procedures, three (10%): first 2 TUI, 1 HN; second 3 TUI; third 2 E&R, 1 HN. Four procedures, two (7%): first 2 TUI; second 1 HN, 1 TUI; third 2 TUI; fourth 2 E&R. Eight (27%) remained on prophylaxis: two had no intervention, in 4 the ectopic ureterocele was in situ after HN or TUI, and two had reflux after E&R. Twenty two (73%) came off prophylaxis (16 E&R, 4 HN, 1 TUI, 1 observation). Poorly or non-functioning upper pole moieties were left in place in 14/18 who underwent E&R. Conclusion ‘Treatment-free’ status most often requires ureterocele excision. HN alone can be definitive, while TUI alone is so rarely. Poor or non-functioning upper pole segments can remain after E&R. Children with collapsed ureteroceles in situ often must remain on antibiotic prophylaxis. A staged approach with initial TUI, followed by E&R, was successful in definitively treating the majority.

One stage laparoscopic hemi-nephroureterectomy with excision of ureterocele and ureteric reimplantation: long term outcome

Purpose To evaluate the long term outcome after the one-stage laparoscopic hemi-nephroureterectomy with simultaneous excision of ureterocele, and reimplantation of the normal moiety ureter. Material and methods Nineteen patients (M/F: 3/16) underwent the procedure. Mean age at surgery was 1.81years (range 1m - 7.24 years). All patients had a duplex system with a non- functioning upper moiety and large complicating ectopic caecoureterocoeles which persisted despite previous cystoscopic incision. VUR occurred in 8 patients (3 bilateral). All patients underwent the one - stage laparoscopic procedure via a transperitonial route with endoscopic upper pole heminephrectomy with extravesical excision of the ureterocele, and reimplantation of the lower moiety ureter. All patients were regularly followed every 3 months and repeated radiological assessments including US, VCUG and DMSA were done at 12 months and then at yearly interval afterwards. Complete resolution of the VUR was confirmed based on negative findings on follow up VCUG. Results The procedure was successful in all patients and no procedure-related complications were observed. Mean follow up was 4.45 years (range.1.1 – 8 yrs). None of the patients in this series showed functional loss in the remaining ipsilateral moiety. Follow-up cystogram showed complete resolution of VUR in all 8 patients (100 %). Two patients developed UTI during the follow up period and none of them developed a new renal scar. Cosmetic results were excellent in all patients and no long-term complications have been encountered so far. Conclusions Our experience demonstrates that this radical definitive surgery can be safely and effectively performed in a single stage laparoscopic procedure. The procedure minimizes the hazards of traditional open surgical reconstruction. Furthermore, the long-term successful outcome in our series establishes this unique procedure as safe and effective in treating infants with renal duplication associated with ectopic ureteroceles.

Effectiveness of primary endoscopic incision of ureteroceles.

Endoscopic incision of a ureterocele (EIU) is simple when compared to an open procedure such as ureterocele excision with or without an upper-pole nephrectomy. It has, however, the potential to induce vesicoureteric reflux (VUR), which traditionally requires further surgical intervention. The natural history of the VUR that develops following EIU is not known. We have treated asymptomatic VUR that developed following EIU conservatively and have surgically intervened only in cases with recurrent urinary tract infections (UTI). This is a review from a single surgeon's practice involving 29 consecutive cases of ureterocele spread over a period of 4 years. The range of follow up was 4-54 months (median 32). Of the 24 children who underwent primary EIU, 6 required a second procedure, 3 a reincision and 3 an open procedure. Of the 3 who had a reincision, 2 required a further open procedure. The indication for reincision was failure of decompression of the upper tract and the indication for an open procedure was recurrent UTI following EIU. Thus, overall success was achieved in 19 of 24 cases of primary EIU (79.2%). VUR following EIU appeared in 10 cases (41%); UTI developed in only 5 (50%) of these 10 cases. Overall, UTI developed in 6 of the 24 (25%) cases of primary EIU. Eight children had an open procedure (3 as a primary procedure and 5 after EIU); 2 (25%) from this group had UTI following the procedure, and interestingly, neither had VUR. Ureterocele incision is thus a good alternative to upper-pole nephrectomy or excision of the ureterocele, especially in infancy. There is an inherent risk of producing VUR in the postincision period, however, the majority of cases can be managed conservatively. All patients need to be monitored for hypertension and UTI following EIU.

ECTOPIC URETEROCELE:: RESULTS OF OPEN SURGICAL THERAPY IN 40 PATIENTS

The treatment of ectopic ureterocele is controversial. In addition to debate on optimal therapy, discussion exists on whether there is further risk of deteriorating bladder function after extensive bladder surgery during the first year of life, which is a reason to postpone surgery. In a prospective nonrandomized trial we treated 40 patients regardless of age who had ectopic ureterocele with complete surgical reconstruction of the lower urinary tract and upper pole resection of poorly functioning upper pole moieties at referral. Excluded from study were 3 patients with only 1 affected renal moiety initially. We treated 31 female and 9 male patients 0 to 8.8 years old (mean age 2.17) at surgery for ectopic ureterocele extending into the bladder neck and urethra, including 19 younger than 1 year. Primary ureterocele excision was performed in 37 cases with reconstruction of the urethra, bladder neck and trigone, and ureteral reimplantation. Because of small ureterocele size, the ureterocele was left in situ in 3 patients, leading to secondary ureterocele removal due to obstructive voiding and urinary incontinence in 1 each. A staged procedure in 5 neonates involved primary lower urinary tract reconstruction with upper pole cutaneous ureterostomies followed by upper pole resection or ureteral reimplantation a few months later. After bladder neck reconstruction in 16 cases colposuspension was also done to create a normal vesicourethral angle. All patients underwent clinical and urodynamic evaluation at least 1.25 years after surgery (mean followup 5.59). Patients who were too young for the clinical assessment of continence by January 1999 were excluded from study. All patients are continent. A secondary endoscopic procedure was required in 13 cases, including cystoscopy only in 2, scar incision near the ureteral orifice in 3, endoscopic reflux treatment in 4, ureterocele remnant resection in 2 and bladder neck incision for obstructive voiding in 2. Secondary open bladder reconstruction was performed in another case due to a diverticulum. Postoperatively only 1 or 2 uncomplicated episodes of urinary tract infection developed in 11 patients, while there were recurrent urinary tract infections in 4. In a patient with a preexisting loss of renal function a severe infection led to renal scarring. The voiding pattern was normal in 29 patients but 11 had dysfunctional voiding, including 5 with recurrent urinary tract infection. Urodynamic followup confirmed these clinical findings. Bladder capacity in these patients was relatively high at an average of 124% of expected capacity for age. We noted no statistically significant difference in followup parameters in patients who underwent surgery before and after age 1 year. Additional colposuspension in 16 patients did not result in any significant change in outcome compared with that in patients without this procedure. When compared with results in the literature, complete primary lower urinary tract reconstruction in patients with ectopic ureterocele appears to have better results than a staged approach with initial endoscopic treatment. Moreover, our study provides no proof that extensive reconstructive bladder surgery in neonates and infants leads to bladder function deterioration at a later age.

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 of transurethral puncture of ectopic ureteroceles: initial success and late problems.

We studied the long-term outcome of transurethral puncture of ectopic ureteroceles specifically associated with duplex systems. We retrospectively reviewed the records of patients who underwent transurethral puncture of an ectopic ureterocele. Study exclusion criteria were orthotopic, bilateral and prolapsing ureteroceles. 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. 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.

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.

Surgical management of duplex ureteroceles

We reviewed the cases of 95 children with duplex ureteroceles treated in this department over an 18-year period. There were 101 ureteroceles (6 bilateral). Diagnosis and treatment were analyzed. Special attention was paid to newborns screened in utero. We always strove to preserve functional renal tissue whenever possible. In keeping with this goal, three surgical techniques were used: (1) upper pole heminephrectomy; (2) ureterocele excision, bladder neck reconstruction, and ureter reimplantation with or without cutaneous ureterostomy of the upper pole ureter; and (3) endoscopic ureterocele incision. Follow-up studies using x-ray and radionuclide imaging demonstrated satisfactory renal function in 86.6% of patients. These findings support a conservative approach to ureteroceles using endoscopic ureterocele incision as the primary treatment. Lower urinary tract reconstruction may be associated in cases involving urinary tract infection, obstruction or incontinence. Upper pole heminephrectomy should be performed only after functional evaluation following ureterocele incision or cutaneous ureterostomy.

Surgical management of ectopic ureterocele

Nine patients with ectopic ureterocele, complete duplication, and nonvisualization of the upper renal segment are presented. All were managed with heminephrectomy and partial ureterectomy only. The procedure immediately controlled urosepsis, and ultimately was successful in the management of associated reflux. Excision of ureterocele and reimplantation of the ipsilateral ureter was unnecessary.