Transurethral Incision for Ureterocele
Dacia Di Renzo, MD1, Pamela I. Ellsworth, MD2, Pierluigi Lelli Chiesa, MD1, Anthony A. Caldamone, MD2.
1Pediatric Surgery Department “D’Annunzio University, Chieti-Pescara, Italy, 2Rhode Island Hospital, Providence, RI
BACKGROUND: The management of ureteroceles remains controversial with many options available. We present our experience with transurethral endoscopic incision (TUI) of ureterocele (UC) and analyze our outcomes to better predict which patients should be considered candidates for this treatment.
METHODS: Over the last 15 years (1994-2008) at two institutions 47 patients (median age 2 months, range 1 day-23 years) with a total of 50 UC underwent primary TUI. Prenatal ultrasound detected hydronephrosis in 34 cases (68%); in the remaining the diagnosis was made on evaluation for urinary tract infection (UTI). UC was intravesical in 25 units (50%), ectopic in 25 (50%) and it presented as a part of duplex system (DS) in 34 cases (68%) and of a single system (SS) in 16 (32%). Pre and post TUI evaluations included US and VCUG or voiding urosonography in all patients; the majority underwent nuclear scan (DMSA, MAG3 or DTPA) and/or intravenous pyelogram pre and/or post TUI. Mean follow-up was 7 years (range 6 mos-15 ys).
RESULTS: In 28 UC units (56%) TUI was the only management, with 2 patients requiring a repeat TUI. The remaining 22 (44%) underwent further procedures for high grade VUR, persistent hydronephrosis, UTIs or nonfunctioning upper pole (UP)/kidney. Overall 30 of 50 UC units (60%) did not require open surgery. Regarding the type of renal unit and the UC location, TUI alone was effective in 81% of SS and 72% of intravesical UC; in ectopic and DS cases, TUI was successful alone in 42% and 44%, respectively.Prior to TUI, VUR was present in 19 patients (16 with VUR in one ureter; 3 with VUR in more than one ureter), with a total of 23 refluxing units. Resolution of VUR after TUI was seen in 10 of 23 refluxing ureters (44%) and in 4 (17%) VUR was downgraded. 30 of 50 UC units had no VUR before TUI: 20 of these (66%) had TUI only, the remaining 10 (33%) required secondary procedures. Of the 50 punctured UC, in 15 (30%) de novo VUR to the UC moiety occurred. In 8 of these 15 cases (53%) the de novo VUR spontaneously resolved or patients did well with or without antibiotic prophylaxis. 7 UC units with de novo reflux (46%) required surgery, in 2 of these 7 VUR was also present pre-TUI. 11 (22%) ipsilateral UP or kidneys were nonfunctioning; 5 were removed because of high grade hydronephrosis; those left in place did not develop symptoms.
CONCLUSIONS: Our results indicate that the success of TUI for initial management of ureteroceles is dependent on several factors: the status of the upper tracts (single vs. duplex), the presence or absence of reflux (contralateral or ipsilateral or both), and the status of the UC (intravesical vs. extravesical). Neither presentation nor age of the patient influenced the result of TUI regarding the need for subsequent surgery. The best outcomes for TUI are in single renal systems and intravesical ureterocele. This information should be used in considering options for initial ureterocele management.