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Lower Urinary Tract Reconstruction for Ureteroceles

I. Straticiuc-Ciongradi¹, S.G. Aprodu¹, V. Munteanu², S. Gavrilescu¹

¹Pediatric Surgery Department

²Department of Pediatric Intensive Care

“Sf Maria” Children Hospital, Iasi, Romania

 

Correspondence:

Sandu Gabriel Aprodu, MD, PhD

Department of Paediatric Surgery,“Sfanta Maria” Children Hospital,

Vasile Lupu Street 62, 700309, Iasi, Romania

E-mail : This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Purpose: The therapeutically approach to ureteroceles is very controversial. We performed the lower urinary tract reconstruction as primary treatment for those patients.

Materials and Methods: We present the experience of our institution using definitive lower urinary tract reconstruction without upper tract ablative surgery in 16 patients with single and double collecting systems and associated ureterocele.

Results: Average age at the time of reconstruction was 19 months. There were 5 single unit ureteroceles, and 11 double system ureteroceles. All of our patients underwent surgical excision of the ureterocele and ureteral reimplantation. Three of the cases needed subsequent upper pole heminefrectomy.

Conclusions: Lower urinary tract reconstruction for ureteroceles is an effective treatment for patients with ureterocele, with a low morbidity and reintervention rate.

Keywords: Ureterocele, ureteral reimplantation, renal duplication

  

Introduction

The management of ureterocele patients is controversial. There are many possibilities in the therapeutically approach of patients, including endoscopic treatment, surgery of the upper urinary tract (heminefrectomy) or lower urinary tract (ureterocele excision and antireflux reimplantation. The management of these patients must be individualized based on several facts as: the number and function of the renal moieties, the importance of the obstruction, the ureteroceles impact on the renal unit drainage and on the bladder neck function, the presence or not of the vesico-ureteral reflux and, maybe the most important of all, the position of the ureterocele (intra or extravesical). Herein, we present our experience of lower urinary tract reconstruction (ureterocele excision and antireflux reimplantation) as therapeutically approach for ureterocele.

Materials and Methods

The medical records of 16 patients who underwent lower urinary tract reconstruction between January 1997 and December 2007, for treatment of ureteroceles were reviewed. We retrospectively analyzed the age at surgery, sex, clinical symptoms, radiological records, type of treatment, postoperative outcomes. Lower urinary tract reconstruction was made by a Phannensteil incision, with a longitudinal bladder opening. The ureterocele was identified and excised. Leadbetter Politano antireflux procedure was performed. The ureters from the duplicated units ureterocele were together reimplantated. None of the ureters required tapering. The procedure was protected with ureteral catheters for 10 days. For preventing extravesical collections all patients had paravesical drainage. All of the cases had intraoperative bladder urine sample prelevated. The uretrovesical drainage was kept for 10 days. For preventing post surgical infections i.v. antibioprofilaxy was given.

Results

Average age at the time of reconstruction was 19 months (range from 2 to 72). No patient had previously undergone upper tract surgery, endoscopic excision or ablative surgery at the time of lower urinary tract reconstruction. Fifty-six percent of the cases were treated under the age of 36 months. Unfortunately none of our patients had prenatal diagnostic (Table 1).

Table 1. Age at the time of reconstruction

 

Single system

Double system

< month

-

1

1 month – 1 year

1

4

1-3 years

-

3

3-6 years

4

3

ureteroceles 1 ureterocele 2
Figure 1. Prolabated ureterocele Figure 2. Duplex system ureterocele
ureterocele 3 ureterocele 4
Figure 3. Intraoperator aspect Figure 4. Upper pole heminefrectomy

Thirty-one percent of the cases (5 children) were associated with a single renal unit, and 11 cases (69%) were duplicated. Three of the patients with double sistem also had controlateral duplicated unit, 2 of them with gradeIV-V vesicoureteral reflux in these units. None of the simplex unit ureteroceles had controlateral associated anomalies.

Five patients (63%) of the duplicated cases were girls, and all of the simplex cases were boys.

Initial presentation consisted of urinary tract infection (15 patients). One female new-born was referred with an acute obstructive renal failure caused by a prolabated ureterocele (fig. 1).

All patients were evaluated preoperatively by bladder and kidney ultrasound, voiding cystourethrography and intravenous urography. Preoperative radiological findings, surgical procedure performed and clinical and radiological follow-up data were collected retrospectively.

For technical reasons, due to the lack of the radioisotope, only 3 children had renal scintigraphy (including diuretical renography). None of the patients had urodinamic studies. All of the 16 cases were operated on. It was performed excision of the ureterocele and ureteral reimplantation. This was completed in 2 cases by controlateral ureteral reimplantation for high grade reflux. Only one case developed an acute postsurgical urinary tract infection with piocianic bacillus, which only needed specific antibiotherapy.

Six months after surgery all patients showed a lowering in the hydronefrosis grade. The vesico ureteral reflux was absent or grade I in 15 cases at control uretrocystography. Only one child with ureterocele and duplication had a grade V reflux, which was associated with multiple urinary tract infections. This case was reoperated 1 year later (antireflux procedure).

Three cases (18%), all with ureterocele associated with the nonfunctional upper pole, needed upper polar heminefrectomy, caused by repeated urinary tract infections (fig. 4). One of these children was referred 2 months after lower urinary pole reconstruction with urosepsis. None of them required other surgical procedure.

Discussion

The incidence of ureteroceles is estimated at 1/4,000 live births and the treatment of these patients are still controversial.

Traditional management of nonfunctional renal segments, either single or double, has consisted of removal of the nonfunctioning moiety. The management of double systems by upper pole heminephrectomy is not without potential morbidity[1]. The risk of vascular compromise and associated loss of the functioning lower pole moiety was reported in 6% of 33 children, treated with upper pole heminephrectomy for ureterocele[2]. Serious complications are known to occur with nephron sparing surgeries such as fistula, acute renal failure, hemorrhage and thrombosis. More importantly, upper tract ablative surgery does not always definitively cure the original lower urinary tract pathology that gave rise to the nonfunctional segment. When upper tract surgery is performed alone, with radiological evidence of vesicoureteral reflux preoperatively, subsequent surgery has been reported to be necessary in 84% of patients. The indication for reoperation is most often persistent or delayed onset reflux, or recurrent urinary tract infections attributed to reflux and/or stasis of urine in the remnant distal ureteral stump.[3]

The endoscopic treatment of ureteroceles is also controversial. A small endoscopic incision of the ureterocele in infants was described by Monfort et al.[4] The percentage of patients with endoscopic treatment of ureteroceles undergoing additional operations is reported from 27% to 41% by different authors , most of all due to the high grade vesico ureteral reflux . A high percentage of children with extravesical ureteroceles will require additional surgery following puncture. [5,6,7]

The use of a lower tract approach for uretocele treatment is based on the traditional management of vesicoureteral reflux or ureterovesical obstruction[8]. This approach allows the surgeon to excise the ureterocele and also to perform antireflux surgery with or without ureteral tapering on the affected side and also , if necessary on the controlateral side. The percent of these cases that will need further surgery is low, even if the ureterocele is draining a nonfunctional renal unit. Concerns have been expressed regarding increased risks of development of hypertension, proteinuria and malignancy, as well as urinary tract infections, with surgical approaches that leave behind nonfunctioning renal moieties[9]. To our knowledge there is no case of hypertension caused by leaving a nonfunctioning upper renal pole segment in situ reported in the literature. None of our cases, with a minimum 6 years follow up , developed hypertension or malignancies.

Conclusions

The appropriate protocol for managing ureterocele is controversial. Endoscopic treatment as well as upper pole nephrectomy is associated with a high reoperation rate of 25% to 100% in the literature, especially when there was reflux into 1 or more moieties. These facts and our experience with morbidity and reoperation in children who undergo staged procedures led to our choice of primary and complete surgical reconstruction of the lower urinary tract.

 

 

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