Management and outcomes of ureteroceles in children: An experience of 25 years

Surgical patterns in the endoscopic management of pediatric ureterocele: A systematic review and meta-analysis

OBJECTIVE

To assess the results of endoscopic ureterocele treatments as well as the effects of ureterocele location (intravesical vs. ectopic) and anatomy (single vs. duplicated system) on treatment outcomes.

MATERIAL AND METHODS

Following the Systematic Reviews and Meta-Analyses (PRISMA) standards, several medical databases as well as Google Scholar were searched comprehensively. Studies describing secondary operation outcomes for endoscopic transurethral incision and puncture were included. Studies were required to compare patients according to ureterocele location (intravesical or ectopic) and anatomy (single or duplex system) or preoperative reflux. Meta-analysis was conducted using Comprehensive Meta-analysis (CMA) software.

RESULTS

A total of 83 studies entered this systematic review consisting of 3022 patients. According to the meta-analysis of 16 studies, the risk ratio (RR) of reoperation after ureterocele incision was significantly higher in patients with ectopic vs. intravesical ureteroceles (RR: 2.42; 95% CI: 1.89-3.11; P < 0.001; I2: 14.89%). Also, a higher reoperation rate was reported in patients with duplex system ureteroceles (DSU) vs. single system ureteroceles (SSU) with little heterogeneity based on 9 studies. (RR: 2.50; 95% CI: 1.60-3.91; P < 0.001; I2: 13.83%).

CONCLUSION

Our results showed that ectopic ureteroceles and duplex systems are associated with higher reoperation rates after endoscopic procedures.

Voiding cystourethrography in patients undergoing endoscopic decompression of duplex system ureteroceles: to do or not to do?

OBJECTIVE

To assess the role of voiding cystourethrography (VCUG) in patients with duplex system ureterocele (DSU) undergoing endoscopic decompression (ED).

MATERIALS AND METHODS

This is a retrospective study of 75 consecutive patients with DSU undergoing ED [median (range) age, 6 (1-148) months]. Patients were divided into 3 groups, 33 with a VCUG showing vesicoureteral reflux (VUR) before ED (VUR-group), 22 with a VCUG negative for VUR (No-VUR-group), and 20 who did not undergo a VCUG (No-VCUG-group). Secondary surgery (SS) rate was compared among groups.

RESULTS

Groups were comparable for baseline characteristics. SS rate was 82% (27/33) in VUR-group vs. 32% (7/22) in the No-VUR-group (p = 0.0001), and 25% (5/20) in the No-VCUG-group (p = 0.001 vs. VUR-group, and 1 vs. No-VUR-group). In the VUR-group, 9 patients underwent preemptive endoscopic treatment of VUR during ED and SS rate was 44% (4/9) vs. 96% (23/24) in the remainder, p= 0.003. In the No-VCUG-group, a VCUG was performed during follow-up in 9/15 patients and showed reflux in all, although only 2 of these developed a (single) urinary tract infections.

CONCLUSIONS

SS rate was significantly higher in patients with preoperative VUR. Instead, it was not significantly different between patients without VUR and those who did not undergo a VCUG before ED, despite all the latter who underwent a VCUG during follow-up had evidence of VUR generally in the absence of symptoms. In our opinion, a VCUG could be limited to patients developing symptoms after ED. If a VCUG is performed before ED, a preemptive treatment of VUR should be taken into consideration.

Associations of ureteroceles location and system anatomy with outcomes of endoscopic treatment: A systematic review and meta-analysis

INTRODUCTION

Ureteroceles are a congenital abnormality of the ureter that can cause significant complications. Endoscopic treatment is a commonly used treatment approach. The aim of this review is to assess the results of endoscopic treatment for ureteroceles with consideration to their location and system anatomy.

METHODS

A meta-analysis was conducted by searching electronic databases for studies comparing outcomes of endoscopic treatment for ureteroceles. Newcastle-Ottawa Scale (NOS) was employed to evaluate the potential for bias. The primary outcome was the rate of secondary procedures required following endoscopic treatment. Secondary outcomes were inadequate drainage and post-operative vesicoureteral reflux (VUR) rates. A subgroup analysis was performed to investigate possible causes of heterogeneity in the primary outcome. The statistical analysis was conducted using Review Manager 5.4.

RESULTS

There were 28 retrospective observational studies, published between 1993 and 2022, including 1044 patients with primary outcomes in this meta-analysis. The quantitative synthesis showed that ectopic and duplex system ureteroceles were significantly associated with higher rate of secondary operation compared to intravesical and single system ureteroceles, respectively (OR: 5.42, 95% CI: 3.93-7.47; and OR: 5.10, 95% CI: 3.31-7.87). The associations were still significant in subgroup analysis based on follow up duration, average age at surgery, and duplex system only. For secondary outcomes, incidence of inadequate drainage were significantly higher in ectopic (OR: 2,01, 95% CI: 1.18-3.43), but not in duplex system ureteroceles (OR: 1.94, 95% CI: 0,97-3.86). Post-operative VUR rates were higher in both ectopic (OR: 1.79, 95% CI: 1.29-2.47) and duplex system ureteroceles group (OR: 1.88, 95% CI: 1.15-3.08).

CONCLUSION

Ectopic ureteroceles and duplex system ureteroceles were associated with worse outcomes following endoscopic treatment compared to intravesical and single system ureteroceles, respectively. It is recommended to carefully select patients, conduct pre-operative evaluations, and closely monitor patients with ectopic and duplex system ureteroceles.

Retrograde incision from orifice (RIO) technique for endoscopic incision of ureterocele: 15 years of outcomes

INTRODUCTION

Management of obstructing ureterocele often includes endoscopic transurethral incision (TUI) that can be challenging secondary to uncertainty in anatomic landmarks with risk of serious complications. To this end, we innovated a technique using predictable landmarks that begins endoscopic incision at the ureterocele orifice and extends retrograde proximal to the bladder neck (Figure).

OBJECTIVE

With over 15 years of experience in performing this retrograde incision from orifice (RIO) technique, we aimed to examine post-operative outcomes and risk of surgical failure after RIO compared to traditional TUI techniques for ureteroceles. We hypothesized that clinical outcomes after RIO would be superior to traditional endoscopic approaches to decompression of obstructing ureterocele in infants.

STUDY DESIGN

A retrospective study of patients ≤12 months old who underwent TUI ureterocele at our institution between 2007 and -2021 was conducted. Pre-, intra- and post-operative characteristics were compared between patients who underwent RIO vs non-RIO TUI. Primary outcome was post-incision febrile urinary tract infection (fUTI). Secondary outcome was a composite failure measure of fUTI, secondary surgery, de novo bladder outlet obstruction, or vesicoureteral reflux. Multivariable Cox proportional hazard models were fitted to compare the time-to-event risk of primary and secondary outcomes between groups.

RESULTS

Ninety patients with 92 ureteroceles were included (49 RIO, 43 non-RIO). Median follow-up from TUI was 33 months. RIO had a shorter median operative duration (27 vs 35 min, p = 0.021). Primary and secondary outcomes were similar between groups (fUTI: 29% RIO vs 19% non-RIO, p = 0.27; composite failure 54% RIO vs 69% non-RIO, p = 0.15). In multivariable Cox proportional hazard models, there was no significant difference in risk of fUTI (RIO aHR 0.98, 95% CI 0.38-2.54, p = 0.97) or composite failure (RIO aHR 0.80, 95% CI 0.45-1.44, p = 0.46) between TUI techniques.

DISCUSSION

RIO technique for TUI ureterocele is attractive in that it uses predictable anatomic landmarks making it simple to perform. In analyzing this 15-year institutional experience of TUI ureterocele, RIO showed similar success to non-RIO endoscopic incisions. This study is a retrospective, non-randomized, single-institutional study over 15 years and is therefore subject to change in surgeon practice over time and variable practices between providers.

CONCLUSIONS

Given comparable success and durability over time to other TUI ureterocele techniques, and with the advantage of operator ease using consistent anatomic landmarks, RIO is a worthy option for endoscopic ureterocele decompression.

Inferior Vena Cava Agenesis Associated with Urogenital Anomalies: A Case Report

BACKGROUND

Inferior vena cava (IVC) agenesis, ectopic ureterocele and ureteral duplication are very rare congenital anomalies.

CASE PRESENTATION

A-25-year-old female patient was referred with right flank pain, chills and dysuria. Laboratory tests and CT showed findings consistent with acute pyelonephritis. There were only frequent urinary tract infections and Factor V Leiden mutation in her medical history. Patient was treated with antibiotherapy. CT examination demonstrated IVC agenesis (IVCA). Urogenital anomalies such as vaginal ectopic ureterocele, ureteral duplication and septate uterine anomaly were also present.

CONCLUSION

We report the first occurrence of IVC agenesis associated with multiple urogenital anomalies in the literature.

De Novo Vesicoureteral Reflux Following Ureterocele Decompression in Children: A Systematic Review and Meta-Analysis Comparing Laser Puncture versus Electrosurgical Incision Techniques

Background: The available endoscopic techniques for ureterocele decompression include laser puncture (LP), electrosurgical incision (ES), and cold-knife incision. This systematic review was performed to compare the efficacy of LP versus ES techniques with special emphasis on de novo VUR. Methods: Four databases were systematically searched by the authors. The inclusion criteria were all comparative studies in which ureterocele decompression was performed by either LP or ES endoscopic techniques. Outcomes including the incidence of de novo VUR, the need for endoscopic retreatment of the ureterocele, and the need for secondary surgical procedures were studied. Risk ratios (RR) were calculated for all outcomes and the Mantel-Haenszel method was utilized for the estimation of pooled RR. The methodological quality was assessed by the Downs and Black scale. Results: Five studies were considered for systematic review, while four of them were included in the meta-analysis. Out of 202 children, 67 developed de novo VUR. Significantly lower rates of reflux were observed in the LP group vis-a-vis ES group (RR = 0.17, 95% CI 0.09 to 0.32, p < 0.00001). Endoscopic retreatment rates (n = 20) demonstrated no significant difference among the two patient groups (RR = 0.66, 95% CI 0.26–1.68, p = 0.38). A total of 46 secondary procedures were performed in 170 children, mostly ureteral re-implantations, with a significantly lower need of secondary surgeries following LP versus ES (RR = 0.26, 95% CI 0.13–0.49, p < 0.0001). The risk of bias in the included studies was low-to-moderate. Conclusions: When compared to the ES technique, the LP technique is associated with a significantly low incidence of de novo VUR and requirement for secondary surgeries (particularly anti-reflux surgeries). Endoscopic retreatment rates showed no significant difference between the two techniques. However, due to the moderate risk of bias in two out of four included studies, randomized controlled trials are needed in the future.