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Li Z, Yang K, Du Y, Li X, Li Z, Wang B, Huang C, Chen S, Zhang Y, Zhu H, Zhang P, Zhou L, Wang G, Li X. Endoscopic Management of Adult Primary Obstructive Megaureter: Techniques and Long-term Outcomes. EUR UROL SUPPL 2024; 68:18-24. [PMID: 39257619 PMCID: PMC11381473 DOI: 10.1016/j.euros.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/12/2024] Open
Abstract
Background and objective Few studies on endoscopic management of primary obstructive megaureter (POM) in adult patients have been reported. Our objective was to describe our technique and long-term outcomes for endoscopic management of adult POM. Methods We included 76 adult POM patients undergoing endoscopic management between September 2015 and January 2024. Under endoscopic control, the stricture was dilated to 24-30 Fr while maintaining a balloon pressure of 25-35 atm for 3 min. An additional incision of the stenotic ring using either an electrode or holmium laser was performed in 39 patients. Data for patient characteristics, intraoperative variables, surgical complications, and follow-up results were analyzed. A descriptive statistical analysis was performed. Surgical success was defined as no tubes or stents in the body, stable or improved symptoms and renal function, and the absence of reflux or obstruction during the follow-up period. Key findings and limitations All procedures were completed without conversion to open or laparoscopic surgery. The median operative time was 45 min (range 16-165) with median estimated blood loss of 2 ml (range 0-150). The median postoperative hospital stay was 3 d (range 1-15). No intraoperative complication occurred. At median postoperative follow-up of 42 mo (range 3-100) the overall success rate was 92.1%. Restenosis of the vesicoureteral junction (Clavien-Dindo grade III) occurred in five patients (6.6%), and high-grade vesicoureteral reflux occurred in one patient (1.3%), all of whom required secondary reconstruction surgery. Conclusions and clinical implications The results indicate that our endoscopic management for adult POM is safe and effective, with favorable long-term outcomes. This approach could potentially serve as a first-line treatment option for adult POM. Patient summary Primary obstructive megaureter (POM) occurs when the flow of urine is blocked because of a narrow segment in the tube between the kidney and bladder (ureter), which causes widening of the ureter further up. For our minimally invasive technique, a telescope is inserted through the urethra and bladder to reach the ureter for surgical treatment. Our results show that this is a safe procedure for POM in adults.
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Affiliation(s)
- Zhenyu Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Kunlin Yang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Yicong Du
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Xinfei Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Zhihua Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Bing Wang
- Department of Urology, Miyun Hospital, Peking University First Hospital, Beijing, China
| | - Chen Huang
- Department of Urology, Beijing Jiangong Hospital, Beijing, China
| | - Silu Chen
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Yiming Zhang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Hongjian Zhu
- Department of Urology, Beijing Jiangong Hospital, Beijing, China
| | - Peng Zhang
- Department of Urology, Emergency General Hospital, Beijing, China
| | - Liqun Zhou
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Gang Wang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Xicheng District, Beijing, China
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Boswell TC. Advancements in Surgical Management of Megaureters. Curr Urol Rep 2024; 25:215-223. [PMID: 38954357 PMCID: PMC11306539 DOI: 10.1007/s11934-024-01214-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To review and describe the recent evolution of surgery for the various types of pediatric megaureter. RECENT FINDINGS Megaureter management first relies on determining the underlying cause, whether by obstruction, reflux, or a combination, and then setting appropriate surgical indications because many cases do not require surgery as shown by observation studies. Endoscopic balloon dilation has been on the rise as a major treatment option for obstructive megaureter, while refluxing megaureters can also be treated by laparoscopic and robotic techniques, whether extravesically or transvesicoscopically. During ureteral reimplantation, tapering is sometimes necessary to address the enlarged ureter, but there are also considerations for not tapering or for tapering alternatives. Endoscopic and minimally invasive surgeries for megaureter have been the predominant focus of recent megaureter literature. These techniques still need collaborative prospective studies to better define which surgeries are best for patients needing megaureter interventions.
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Affiliation(s)
- Timothy C Boswell
- Department of Urology, Children's of Alabama and University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 318, Birmingham, AL, 35233, USA.
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Pérez-Bertólez S, Martín-Solé O, Casal-Beloy I, Carbonell M, Salcedo P, Capdevila B, García-Aparicio L. Risk and protective factors for secondary procedures after endoscopic dilatation of primary obstructive megaureters. World J Urol 2024; 42:463. [PMID: 39088058 DOI: 10.1007/s00345-024-05181-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
PURPOSE High-pressure balloon dilatation (HPBD) of the ureterovesical junction with double-J stenting is a minimally invasive alternative to ureteral reimplantation or cutaneous ureterostomy for first-line surgical treatment of primary obstructive megaureter (POM). The aim of our study was to identify the risk factors associated with the need for secondary procedures due to HPBD failure. METHODS Prospective data were collected from patients who underwent HPBD for POM between 2007 and 2021 at a single institution. The collected data included patient demographics, diagnostic modalities, surgical details, results, and follow-up. Multivariate logistic regression analysis was performed. RESULTS Fifty-five ureters underwent HPBD for POM in 50 children, with a median age of 6.4 months (IQR: 4.5-13.8). Nineteen patients (37.25%) underwent secondary ureteric reimplantation, with a median of 9.8 months after primary HBPD (95% CI 6.2-9.9). The median follow-up was 29.4 months (IQR: 17.4-71). Independent risk factors for redo-surgery in a multivariate logistic regression model were: progressive ureterohydronephrosis (OR = 7.8; 95% CI 0.77-78.6) and early removal of the double-J stent. A risk reduction of 7% (95% CI 2.2%-11.4%) was observed per extra-day of catheter maintenance. The optimal cut-off point is 55 days, ROC curve area: 0.77 (95% CI 0.62-0.92). Gender, distal ureteral diameter, pelvis diameter, dilatation balloon diameter and preoperative differential renal function did not affect the need for reimplantation. CONCLUSIONS The use of a double-J stent for at least 55 days seems to avoid the need for a secondary procedure. Therefore, we recommend removing the double-J catheter at least 2 months after the HBPD.
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Affiliation(s)
- Sonia Pérez-Bertólez
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain.
| | - Oriol Martín-Solé
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Isabel Casal-Beloy
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Mar Carbonell
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Paula Salcedo
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Blanca Capdevila
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
| | - Luis García-Aparicio
- Pediatric Urology Unit, Department of Pediatric Surgery, Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig de Sant Joan de Déu, 2. , 08950, Barcelona, Spain
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Rivetti G, Marzuillo P, Guarino S, Di Sessa A, La Manna A, Caldamone AA, Papparella A, Noviello C. Primary non-refluxing megaureter: Natural history, follow-up and treatment. Eur J Pediatr 2024; 183:2029-2036. [PMID: 38441661 PMCID: PMC11035438 DOI: 10.1007/s00431-024-05494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/17/2024] [Accepted: 02/23/2024] [Indexed: 04/23/2024]
Abstract
Primary non-refluxing megaureter (PMU) is a congenital dilation of the ureter which is not related to vesicoureteral reflux, duplicated collecting systems, ureterocele, ectopic ureter, or posterior urethral valves and accounts for 5 to 10% of all prenatal hydronephrosis (HN) cases. The etiology is a dysfunction or stenosis of the distal ureter. Most often PMU remains asymptomatic with spontaneous resolution allowing for non-operative management. Nevertheless, in selective cases such as the development of febrile urinary tract infections, worsening of the ureteral dilatation, or reduction in relative renal function, surgery should be considered. CONCLUSION Ureteral replantation with excision of the dysfunctional ureteral segment and often ureteral tapering is the gold-standard procedure for PMU, although endoscopic treatment has been shown to have a fair success rate in many studies. In this review, we discuss the natural history, follow-up, and treatment of PMU. WHAT IS KNOWN • PMU is the result of an atonic or stenotic segment of the distal ureter, resulting in congenital dilation of the ureter, and is frequently diagnosed on routine antenatal ultrasound. WHAT IS NEW • Most often, PMU remains asymptomatic and clinically stable, allowing for non-operative management. • Nevertheless, since symptoms can appear even after years of observation, long-term ultrasound follow-up is recommended, even up to young adulthood, if hydroureteronephrosis persists. • Ureteral replantation is the gold standard in case surgery is needed. In selected cases, however, HPBD could be a reasonable alternative.
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Affiliation(s)
- Giulio Rivetti
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Pierluigi Marzuillo
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy.
| | - Stefano Guarino
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Anna Di Sessa
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Angela La Manna
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Anthony A Caldamone
- Division of Urology, Warren Alpert School of Medicine at Brown University/Hasbro Children's Hospital, Providence, RI, USA
| | - Alfonso Papparella
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
| | - Carmine Noviello
- Department of Woman, Child and of General and Specialized Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Via Luigi De Crecchio 2, 80138, Naples, Italy
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Mele E, Ghidini F, Contini G, Capozza N, Castagnetti M. Risk Factors for Failure of Endoscopic Balloon Dilatation of Primary Obstructive Megaureter: Single-Center 12-Year Experience with 123 Cases. J Endourol 2024; 38:480-487. [PMID: 38450567 DOI: 10.1089/end.2023.0550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Purpose: To review our experience with >100 patients with primary obstructive megaureter (POM) undergoing endoscopic balloon dilatation (EBD) and a follow-up of up to 12 years and determine potential risk factors for failure. Our hypothesis is that EBD allows for long-term treatment in >80% of patients, and its effectiveness decreases in more severe cases. Methods: This is a retrospective study of 123 consecutive patients (131 ureters) undergoing EBD from 2009 to 2021. Indications for EBD included symptoms, worsening dilatation, and/or renal function impairment. Clinical characteristics, complications, and outcomes, including those in the patients with >5-year follow-up, were described. Preoperative and intraoperative markers of severity chosen a priori were tested as risk factors for failure. Failure was defined as the need for ureteral reimplantation after EBD. Results: EBD was feasible in 121 of 123 (98%) patients, regardless of age. After a median follow-up of 38 (9-143) months, EBD was effective in 84.5% of cases. Failures generally occurred in the 1st year after EBD and were seldom associated with permanent loss of renal function. Of the 66 patients with follow-up >5 years, EBD was effective in 56 patients. No preoperative characteristic proved to be a risk factor for failure. The intraoperative absence of a ring was the only significant risk factor for failure, odd ratio 117.86 (95% confidence interval 6.27-2215.84). Conclusions: EBD was feasible and definitive treatment in 85% of our cases, regardless of age. Since this study did not identify preoperative factors to help the clinicians in patient selection, we consider EBD a viable initial procedure in all patients with POM who require surgical intervention, especially in infants.
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Affiliation(s)
- Ermelinda Mele
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Filippo Ghidini
- Pediatric Surgery Unit, Department of Child Health, University Hospital of Modena, Modena, Italy
| | - Giorgia Contini
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Nicola Capozza
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Department of Surgery, Bambino Gesù Children's Hospital, Research Institute, Rome, Italy
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Padua, Italy
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Isac GV, Danila GM, Ionescu SN. Spontaneous resolution and the role of endoscopic surgery in the treatment of primary obstructive megaureter: a review of the literature. LA PEDIATRIA MEDICA E CHIRURGICA 2023; 45. [PMID: 38112615 DOI: 10.4081/pmc.2023.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
The megaureter accounts for almost a quarter of all urinary tract dilations diagnosed in utero and is the second leading cause of hydronephrosis in newborns, following pyeloureteral junction obstruction. The current standard treatment for progressive or persistent, symptomatic primary obstructive megaureter is ureteral anti-reflux reimplantation, which can be associated with ureteral remodeling or plication. Due to the associated morbidity, postoperative recovery challenges, and the complications that may arise from the open surgical approach, there has been a natural inclination towards validating new minimally invasive techniques. This study reviews the literature, extracting data from three major international databases, from 1998 to 2022. Out of 1172 initially identified articles, only 52 were deemed eligible, analyzing 1764 patients and 1981 renal units. Results show that 65% of cases required surgical intervention, with minimally invasive techniques constituting 56% of these procedures. High-pressure endoscopic balloon dilation was the preferred endourologic technique. The degree of ureterohydronephrosis is considered one of the factors indicating the need for surgery. There is an inverse relationship between the diameter of the ureter and the likelihood of spontaneous resolution. Conditions such as renal hypoplasia, renal dysplasia, or ectopic ureteral insertion strongly indicate a poor prognosis. Endoscopic surgical techniques for treating primary obstructive megaureter can be definitive, firstline treatment options. In selected cases, they might be at least as effective and safe as the open approach, but with advantages like quicker recovery, fewer complications, shorter hospital stays, and reduced costs.
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Affiliation(s)
| | - Gabriela Mariana Danila
- Department of Pediatric Surgery and Urology, Maria Sklodowska Curie Emergency Children Hospital, Bucharest.
| | - Sebastian Nicolae Ionescu
- Department of Pediatric Surgery and Urology, Maria Sklodowska Curie Emergency Children Hospital, Bucharest.
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Ortiz R, Burgos L, Fernández-Bautista B, Parente A, Ordóñez J, Angulo JM. Endoscopic balloon dilation of primary obstructive megaureter: is fluoroscopic guidance necessary? World J Urol 2023; 41:2861-2867. [PMID: 37690062 DOI: 10.1007/s00345-023-04572-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE To compare the long-term effectiveness, complications, and outcomes of primary obstructive megaureter (POM) treated by endoscopic balloon dilation under fluoroscopic guidance versus not using radioscopy during the procedure. PATIENTS AND METHODS A comparative study between POM cases treated at our institution by endoscopic balloon dilation (EBD) under fluoroscopic guidance (FG) (n = 43) vs no fluoroscopic guidance (NFG) (n = 48) between the years 2004 and 2018 was conducted. The procedure in FG consisted of performing a retrograde pyelography before dilation. Then, a guidewire is introduced to the renal pelvis, and the dilation of the vesicoureteral junction is performed using high-pressure balloon catheters under fluoroscopic vision. Finally, a double-J stent is placed between the renal pelvis and bladder. The procedure in NFG was performed exclusively under cystoscopic vision without radiological exposure. Complications, outcomes, and success rates were analyzed using Spearman's correlation test. Mean follow-up was 12.5 ± 2.2 years in FG and 6.4 ± 1.3 years in NFG. RESULTS MAG-3 showed significant differences in renal drainage before and after endoscopic treatment in both groups (p < 0.001 T-test). Statistical analysis did not reveal differences between groups in initial technical failure (r: - 0.035, p = 0.74), early postoperative complications (r: - 0.029, p = 0.79), secondary VUR (r: 0.033, p = 0.76), re-stenosis (r: 0.022, p = 0.84), long-term ureteral reimplantation (r: 0.065, p = 0.55), and final outcome (r: - 0.054, p = 0.61). The endoscopic approach of POM had a long-term success rate of 86.5% in FG VS 89.6% in NFG. CONCLUSIONS Endoscopic balloon dilation of POM can be done with no radiation exposure with similar results, effectiveness, and outcomes.
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Affiliation(s)
- Rubén Ortiz
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain.
| | - Laura Burgos
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Beatriz Fernández-Bautista
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Alberto Parente
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Ordóñez
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Jose María Angulo
- Pediatric Urology Division, Department of Pediatric Surgery, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Ripatti L, Viljamaa HR, Suihko A, Pakkasjärvi N. High-pressure balloon dilatation of primary obstructive megaureter in children: a systematic review. BMC Urol 2023; 23:30. [PMID: 36869342 PMCID: PMC9985206 DOI: 10.1186/s12894-023-01199-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVE We 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. METHODS A 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. RESULTS HPBD 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. CONCLUSIONS This 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.
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Affiliation(s)
- Liisi Ripatti
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland.
| | - Hanna-Reeta Viljamaa
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
| | - Anna Suihko
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
| | - Niklas Pakkasjärvi
- Department of Pediatric Surgery, Turku University Hospital, Savitehtaankatu 5, PL 52, 20520, Turku, Finland
- Department of Pediatric Surgery, Uppsala Akademiska Sjukhuset, Uppsala, Sweden
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Li Z, Yang K, Li X, Chen S, Wang X, Li Z, Li X. Minimally invasive ureteral reimplantation or endoscopic management for primary obstructive megaureter: a narrative review of technical modifications and clinical outcomes. Transl Androl Urol 2022; 11:1786-1797. [PMID: 36632159 PMCID: PMC9827399 DOI: 10.21037/tau-22-448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022] Open
Abstract
Background and Objective 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. Methods 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. Key Content and Findings 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. Conclusions The safety and feasibility of MIUR and endoscopic management in patients from all age groups still need further investigation.
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Affiliation(s)
- Zhenyu Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Kunlin Yang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Xinfei Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Silu Chen
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Xiang Wang
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Zhihua Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
| | - Xuesong Li
- Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, China
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Contini G, Mele E, Capozza N, Castagnetti M. Endoscopic balloon dilatation for the treatment of primary obstructive megaureter <24 months of age: Does the size of the balloon influence results? J Pediatr Urol 2022; 19:198.e1-198.e9. [PMID: 36494270 DOI: 10.1016/j.jpurol.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION 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 4 mm vs. 6 mm in diameter. MATERIALS AND METHODS 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 4 mm in group A vs. 6 mm 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). RESULTS 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. DISCUSSION 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. CONCLUSIONS The diameter of the balloon did not influence significantly long-term results, but the 6 mm balloon slightly increased the success rate of EBD to 83.3% and eliminated the need for cutting balloons to achieve a satisfactory dilatation.
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Affiliation(s)
- Giorgia Contini
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Ermelinda Mele
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Nicola Capozza
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marco Castagnetti
- Pediatric Urology Unit, Bambino Gesù Children's Hospital and Research Centre, Piazza S. Onofrio 4, 00165, Rome, Italy; Department of Surgery, Oncology, and Gastroenterology, University of Padova, Padua, Italy.
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Richter J, Rickard M, Kim JK, Erdman L, Lorenzo AJ, Chua M. Predicting the Future of Patients with Obstructive Uropathy—A Comprehensive Review. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00272-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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12
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Postoperative JJ stent is not necessary after balloon high-pressure endoscopic dilatation of primary obstructive megaureter. J Pediatr Urol 2022; 18:369.e1-369.e7. [PMID: 35562267 DOI: 10.1016/j.jpurol.2022.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 03/01/2022] [Accepted: 03/31/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION A wide range of surgical interventions have been described for the management of primary obstructive megaureter (POM). Endoscopic balloon dilatation has been developed through last decades as a minimally invasive alternative to classic surgery. OBJECTIVE To assess the need for placement of a double J stent after endoscopic balloon dilatation procedure, by comparing the post-operative related outcomes with and without double J placement. Secondary outcome was the success rate, considering the need for further procedure after endoscopic balloon dilatation and the improvement of the ureteral diameter in the two groups. STUDY DESIGN Historical retrospective comparison of children treated by endoscopic dilatation for POM, with post-operative JJ stent left in place (2012-2014) or without ureteral JJ stent (since 2015). Post-operative complications were reported following Clavien-Dindo grading system and compared between the two groups. Success rate was defined as absence of need for further surgical reimplantation. Ureteral diameters on preoperative and postoperative renal ultrasounds were compared. RESULTS Endoscopic dilatations were performed in 42 patients for 46 renal units during the study period. There was a significantly higher rate of post-operative complications in the group with JJ stenting compared to the group without double J stenting regarding all Clavien-Dindo grades (56% vs 15%, p = 0.014) and Clavien-Dindo grade III only (31% vs 0%, p = 0,0051) (Figure). The success rate was similar in the JJ group (75%, F-up: 70 months [13-101]) and the no JJ group (81%, F-up: 26 months [12-95]). There was a significant improvement of US renal pelvis and ureter dilatation in both groups, with a median follow-up of 35.5 months [12-101]. DISCUSSION The overall rate of complications was slightly higher than in other reports and higher in the JJ group regarding Clavien-Dindo grade III complications. The success rate was comparable to previous studies reviewing endoscopic dilatations and equivalent in the two groups. CONCLUSION In our study, the omission of postoperative ureteral drainage by a JJ stent after endoscopic balloon dilatation of POM did not increase post-operative complications rate without demonstrable impact on the success rate.
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13
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Baiocco JA, Malhotra NR, Ferrer FA. Bilateral Ureterovesical Junction Obstruction Resulting in Anuria in a Three-Week-Old Infant. Urology 2022; 169:214-217. [PMID: 35623500 DOI: 10.1016/j.urology.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022]
Abstract
Bilateral megaureter with ureterovesical junction obstruction is exceedingly rare. We present a case of a 3-week-old boy who presented in acute renal failure and found to have bilateral megaureter. He was initially decompressed with bilateral percutaneous nephrostomy tubes and once stable underwent bilateral ureterostomy. At 6 months old, renal ultrasound showed stable mild right sided hydronephrosis.
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Affiliation(s)
- Joseph A Baiocco
- Icahn School of Medicine at Mount Sinai, Deparment of Urology; New York, NY.
| | - Neha R Malhotra
- Icahn School of Medicine at Mount Sinai, Deparment of Urology; New York, NY
| | - Fernando A Ferrer
- Icahn School of Medicine at Mount Sinai, Deparment of Urology; New York, NY
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14
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Ordóñez J, Ortiz R, Parente A, Burgos L, Fernández-Bautista B, Pérez-Egido L, Angulo JM. Long Term Outcome of 112 Pediatric Patients With Ureteroplevic Junction Obstruction Treated by Endourologic Retrograde Balloon Dilatation. Front Pediatr 2022; 10:863625. [PMID: 35547531 PMCID: PMC9084922 DOI: 10.3389/fped.2022.863625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To analyze the effectiveness, complications and long-term outcome of the patients with ureteropelvic junction obstruction (UPJO) treated by endoscopic retrograde balloon dilatation (ERBD) in the largest series reported. MATERIALS AND METHODS Between years 2004 and 2018, 112 patients with primary unilateral UPJO were treated by ERBD. Endoscopic treatment consisted on a retrograde balloon dilatation of the ureteropelvic junction (UPJ), through cystoscopy and under fluoroscopic guidance, using high-pressure balloon catheters. In case of persistence in the balloon notch, a Cutting Balloon™ catheter was used. Double-J stent was placed after dilatation. RESULTS Mean age at surgery was 13.1 ± 21.3 months, 92 cases being younger than 18 months. Mean operative time was 24.4 ± 10.3 min; hospital stay was 1 day in 82% of patients. No intraoperative complications occurred. UPJ was calibrated at time of stent removal with cystoscopy 39.1 ± 13.7 days after dilatation. ERBD was not possible in 11 cases. An additional procedure was needed in 24 cases: second ERBD (n = 11, seven during the stent withdrawal), a third dilatation (n = 3) due to persistent hydronephrosis, and percutaneous endopyelotomy (n = 3) or open pyeloplasty (n = 7) in cases of technical failure. Significant improvement in postoperative ultrasound measures were observed (p < 0.05, T-test). Long-term success rate was 76.8% after one dilatation, and 86.6% in those who required up to 2 dilatations. Mean follow-up was 66.7 ± 37.5 months. CONCLUSIONS ERBD is a feasible and safe option for the minimally invasive treatment of UPJ obstruction in infants. Long-term outcome is acceptable with a very low complication rate.
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Affiliation(s)
- Javier Ordóñez
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rubén Ortiz
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Laura Burgos
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Laura Pérez-Egido
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José María Angulo
- Pediatric Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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15
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Demiri C, Lambropoulos V, Mouravas V, Kepertis C, Godosis D, Tsopozidi M, Spyridakis I. Endoscopic treatment of obstructive ureterohydronephrosis in children. Pan Afr Med J 2020; 36:260. [PMID: 33014256 PMCID: PMC7519787 DOI: 10.11604/pamj.2020.36.260.24828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/20/2020] [Indexed: 12/02/2022] Open
Abstract
Obstructive ureterohydronephrosis in childhood population is a matter of debate between paediatric surgeons and paediatricians, as far as the therapeutic protocol that should be applied. Close observation, chemoprophylaxis, endoscopic and surgical approaches are the universally used techniques that provide quality of life in the paediatric patients. Undoubtedly, “the less is more” even when we have to encounter obstructive ureterohydronephrosis in children. Herein, we present a short case series where the endoscopic management of obstructive uropathies proved to be therapeutic without any need of surgical intervention.
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Affiliation(s)
- Charikleia Demiri
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Vassilis Lambropoulos
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Vasileios Mouravas
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Chrysostomos Kepertis
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Dimitrios Godosis
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Maria Tsopozidi
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Ioannis Spyridakis
- Second Department of Paediatric Surgery, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
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16
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Zukunftsprägende Entwicklungen in der Kinderurologie. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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