Current management of ureteroceles

Endoscopic laser-ablation for the treatment of orthotopic and ectopic ureteroceles in dogs: 13 cases (2008-2017)

BACKGROUND

Ureteroceles are a rare condition in dogs in which conventional treatments can result in substantial morbidity. Cystoscopic and fluoroscopic-guided laser ablation (CLA) of ureteroceles can successfully relieve obstruction.

OBJECTIVES

To describe the technique and outcomes of attempting CLA for treatment of ureteroceles in dogs.

ANIMALS

Thirteen client-owned dogs that underwent CLA for treatment of ureteroceles.

METHODS

Retrospective multicentered study. Medical records were reviewed in all dogs that underwent CLA for ureterocele(s). A laser was used to extend the opening of the ureteral orifice (UO) unless surgical conversion was necessary. Data collected included signalment, clinicopathologic data, imaging, procedural findings, complications, and short- and long-term outcome.

RESULTS

Thirteen dogs with 13 ureteroceles associated with 14 UOs resulting in ureteral obstruction were included. One ureterocele extended bilaterally. Treatment was initiated via retrograde cystoscopy (7 females), percutaneous perineal urethrocystoscopy (4 males), or percutaneous antegrade cystoscopy (2 males). Surgical conversion was necessary in 2 males. Ten of 14 (71%) UOs associated with the ureteroceles were ectopic. Thirteen of 14 had stenotic or imperforate UOs. No postoperative complications were noted. Preoperative incontinence or pollakiuria was present in 9 of 13 and 3 of 13 dogs and resolved in 8 of 9 and 3 of 3 dogs, respectively. Follow-up imaging showed resolution of all ureteroceles and improved ureteral/renal pelvic dilatation. Median follow-up time was 27 months (range, 3-96 months).

CONCLUSIONS AND CLINICAL IMPORTANCE

Cystoscopic-guided laser ablation was effective for the treatment of ureteroceles(s) in 11 of 13 dogs.

Transurethral incision of ureteroceles in paediatric age group

OBJECTIVE

Ureteroceles are a great clinical challenge because of variations in anatomy and clinical presentations. We present our experience with primary transurethral incision of ureteroceles in children.

MATERIAL AND METHODS

Data of thirteen children managed for ureterocele from 2009 to 2016 was retrospectively analyzed with respect to age, sex, clinical presentation and symptomatology, type and localization of ureterocele, investigations, surgical management and follow-up.

RESULTS

A total of 13 patients with ureteroceles were managed. There were 7 males and 6 females. Six were neonates with antenatal diagnosis of ureteroceles. Five patients presented with urinary tract infection and two were diagnosed during ultrasound for abdominal pain. The ureteroceles were on the right side in 7 patients and left in 6 patients. Six patients had a duplex system-five on right side and bilateral in one. Two patients had ureteroceles in solitary kidney. Four patients had associated hydronephrosis and hydroureter and two had only hydronephrosis alone. One patient had bilateral grade III reflux in the bilateral lower moieties of the patient with bilateral duplex system. Two patients had poorly functioning kidney on radionuclide scan. All patients underwent cystoscopic incision of the ureteroceles. Eleven had intravesical ureteroceles and two had large caeco-ureteroceles. Two patients required ureteric reimplantation during follow-up.

CONCLUSION

Though the approach of managing a patient with ureterocele should be individualized, transurethral incision remains valuable as a primary intervention with regular follow up. It may even prove to be the only intervention required in most of the patients.

Management of duplex-system ureterocele

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Unusual presentation of bilateral ureteroceles with ureterolithiasis in a patient after robotic prostatectomy

We present a unique case of incidentally discovered symptomatic, stone-laden ureteroceles after robotic prostatectomy at a high-volume institution. The 2-month postoperative timeline to presentation and laser unroofing management strategy for bilateral ureteroceles after robotic prostatectomy are described.

A Meta-Analysis of Surgical Practice Patterns in the Endoscopic Management of Ureteroceles

PURPOSE

We examined the contribution of patient features on reoperation after transurethral incision or puncture in children with ureteroceles.

MATERIALS AND METHODS

A systematic review was accomplished using Medline and article bibliographies to obtain articles related to endoscopic management of ureteroceles in English, Spanish, Italian, French and Japanese. Exposures of interest were ureterocele position and anatomy, and preoperative reflux. The outcome was secondary operation. Meta-analysis was done using Mantel-Haenszel calculations.

RESULTS

Meta-analysis of 10 studies demonstrated that ectopic ureteroceles are associated with significantly greater reoperation rates than intravesical ureteroceles in patients undergoing ureterocele incision. This remains true with longer followup and systematic ureterocele incision/puncture, in neonates and in patients with single and duplex collecting systems. In addition, a meta-analysis of 3 studies showed that patients with duplex system ureteroceles are more likely to require subsequent operation. A third meta-analysis of 7 studies showed that preoperative reflux increases the risk of reoperation after ureterocele incision. More than 1 risk factor did not appear to increase the risk of secondary operation.

CONCLUSIONS

To our knowledge this is the first systematic review of endoscopic ureterocele management. It suggests that ectopic ureterocele location, duplex renal systems and preoperative reflux are proxies for trigonal anatomical distortion, rather than independent risk factors for a secondary operation after incision. Findings reinforce the importance of considering these variables when making management decision in children with ureteroceles.

MR imaging of the bladder

MR imaging is a useful modality for evaluating diseases of the bladder. MR imaging can detect and stage bladder cancer by determining the presence and depth of muscle invasion. Direct multiplanar imaging and superb soft-tissue contrast make MR imaging an ideal modality for evaluating less common neoplastic diseases of the bladder, such as urachal carcinoma, and tumors that develop within bladder diverticula. Dynamic breath-held fast T2-weighted imaging can evaluate for cystocele and other components of pelvic floor relaxation.

Transurethral incision of duplex system ureteroceles in neonates: does it increase the need for secondary surgery in intravesical and ectopic cases?

OBJECTIVE

To evaluate the relevance of ureterocele ectopia and associated reflux on the outcome of duplex system ureteroceles (DSU) after neonatal transurethral incision (TUI).

PATIENTS AND METHODS

The study included 41 neonates with a diagnosis of DSU; the ureterocele was ectopic in 24 (58%). Before TUI, vesico-ureteric reflux (VUR) was present in 13 lower moieties (32%) and seven contralateral ureters (17%). TUI was always performed within the first month of life. The follow-up and management were tailored for each patient from the findings at ultrasonography, voiding cysto-urethrography and renal scintigraphy. Results of intravesical and ectopic DSU were compared using Fisher's exact test.

RESULTS

TUI was effective in allowing ureteric decompression in all but one patient (2.4%). After TUI, VUR ceased in six lower ipsilateral moieties and in two contralateral ureters, while new VUR occurred in three contralateral kidneys. De novo VUR in the punctured moiety appeared in 13 cases (32%). Nine upper poles were not functioning. Twenty-one patients (51%) required secondary surgery. Ureteric reimplantation was indicated exclusively for reflux in the punctured moiety in only in two cases (5%), while in a further two iatrogenic reflux in a nonfunctioning upper moiety required total heminephro-ureterectomy. There was no significant difference between intravesical and ectopic ureteroceles in the occurrence of VUR in the punctured moiety, rate of nonfunctioning upper poles or need for secondary surgery.

CONCLUSIONS

About half of the patients with a DSU need secondary surgery, but this is rarely indicated for de novo reflux in the punctured moiety only. The need for secondary surgery was greater whenever there was associated reflux before endoscopic incision. There was no difference in the outcome of intravesical and ectopic ureteroceles and such distinction seems no longer to be of clinical relevance.

Intravesical ureterocele with concurrent renal dysfunction in a dog: a case report and proposed classification system

A unilateral intravesical ureterocele was diagnosed by ultrasonography in a 5-year-old female Pekingese that was referred for evaluation of increased hepatic enzymes. Ureteroceles are cystic dilatations of the submucosal portion of the distal ureter. They are frequently reported in humans but are uncommonly reported in dogs. This report describes surgical resection of the ureterocele and reduction of ipsilateral hydroureter in a dog that also had bilateral renal dysfunction and suffered progressive mild azotemia postoperatively. This report demonstrates that canine ureteroceles can occur concurrently with bilateral renal dysfunction and offers a classification system designed to encourage thorough urinary tract evaluation for determining prognosis.

Antenatal ultrasonographic development of ureteroceles. Implications for management

Ureteroceles associated with a duplex collecting system may lead to obstructive uropathy, the most common genitourinary anomaly of the fetus. Although most frequently presenting as hydronephrosis, damage from obstruction is a progressive process which may even develop into bilateral renal dysfunction. Antenatal intervention for preservation of fetal renal function may be considered, but must be balanced against procedural risks. Therefore, accurate documentation of the progression may be necessary. In these cases, the development of the classic findings of two ureteroceles are documented over a period of several weeks using serial ultrasonographic evaluation. Postnatal evaluation of the infants confirmed the antenatal findings. The importance of serial ultrasonographic evaluation of fetal obstructive uropathies is dramatically illustrated.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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